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Wang R, Cen M, Huang Y, Qian G, Dean NE, Ellenberg SS, Fleming TR, Lu W, Longini IM. Methods for the estimation of direct and indirect vaccination effects by combining data from individual- and cluster-randomized trials. Stat Med 2024; 43:1627-1639. [PMID: 38348581 DOI: 10.1002/sim.10030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 03/16/2024]
Abstract
Both individually and cluster randomized study designs have been used for vaccine trials to assess the effects of vaccine on reducing the risk of disease or infection. The choice between individually and cluster randomized designs is often driven by the target estimand of interest (eg, direct versus total), statistical power, and, importantly, logistic feasibility. To combat emerging infectious disease threats, especially when the number of events from one single trial may not be adequate to obtain vaccine effect estimates with a desired level of precision, it may be necessary to combine information across multiple trials. In this article, we propose a model formulation to estimate the direct, indirect, total, and overall vaccine effects combining data from trials with two types of study designs: individual-randomization and cluster-randomization, based on a Cox proportional hazards model, where the hazard of infection depends on both vaccine status of the individual as well as the vaccine status of the other individuals in the same cluster. We illustrate the use of the proposed model and assess the potential efficiency gain from combining data from multiple trials, compared to using data from each individual trial alone, through two simulation studies, one of which is designed based on a cholera vaccine trial previously carried out in Matlab, Bangladesh.
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Affiliation(s)
- Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mengqi Cen
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Yunda Huang
- Vaccine and Infectious Disease and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - George Qian
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Natalie E Dean
- Department of Biostatistics & Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Wenbin Lu
- Department of Statistics, North Carolina State University, Raleigh, North Carolina, USA
| | - Ira M Longini
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
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Vail EA, Feng R, Sieber F, Carson JL, Ellenberg SS, Magaziner J, Dillane D, Marcantonio ER, Sessler DI, Ayad S, Stone T, Papp S, Donegan D, Mehta S, Schwenk ES, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Tierney A, Horan AD, Neuman MD. Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial. Anesthesiology 2024; 140:375-386. [PMID: 37831596 DOI: 10.1097/aln.0000000000004807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS Long-term outcomes were similar with spinal versus general anesthesia. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Trevor Stone
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven Papp
- Division of Orthopedics, Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada
| | - Derek Donegan
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Samir Mehta
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut
| | | | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Annamarie D Horan
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
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Snyder PJ, Bauer DC, Ellenberg SS, Cauley JA, Buhr KA, Bhasin S, Miller MG, Khan NS, Li X, Nissen SE. Testosterone Treatment and Fractures in Men with Hypogonadism. N Engl J Med 2024; 390:203-211. [PMID: 38231621 DOI: 10.1056/nejmoa2308836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Testosterone treatment in men with hypogonadism improves bone density and quality, but trials with a sufficiently large sample and a sufficiently long duration to determine the effect of testosterone on the incidence of fractures are needed. METHODS In a subtrial of a double-blind, randomized, placebo-controlled trial that assessed the cardiovascular safety of testosterone treatment in middle-aged and older men with hypogonadism, we examined the risk of clinical fracture in a time-to-event analysis. Eligible men were 45 to 80 years of age with preexisting, or high risk of, cardiovascular disease; one or more symptoms of hypogonadism; and two morning testosterone concentrations of less than 300 ng per deciliter (10.4 nmol per liter), in fasting plasma samples obtained at least 48 hours apart. Participants were randomly assigned to apply a testosterone or placebo gel daily. At every visit, participants were asked if they had had a fracture since the previous visit. If they had, medical records were obtained and adjudicated. RESULTS The full-analysis population included 5204 participants (2601 in the testosterone group and 2603 in the placebo group). After a median follow-up of 3.19 years, a clinical fracture had occurred in 91 participants (3.50%) in the testosterone group and 64 participants (2.46%) in the placebo group (hazard ratio, 1.43; 95% confidence interval, 1.04 to 1.97). The fracture incidence also appeared to be higher in the testosterone group for all other fracture end points. CONCLUSIONS Among middle-aged and older men with hypogonadism, testosterone treatment did not result in a lower incidence of clinical fracture than placebo. The fracture incidence was numerically higher among men who received testosterone than among those who received placebo. (Funded by AbbVie and others; TRAVERSE ClinicalTrials.gov number, NCT03518034.).
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Affiliation(s)
- Peter J Snyder
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Douglas C Bauer
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Susan S Ellenberg
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Jane A Cauley
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Kevin A Buhr
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Shalender Bhasin
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Michael G Miller
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Nader S Khan
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Xue Li
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Steven E Nissen
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
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Hudson J, Cruickshank M, Quinton R, Aucott L, Wu F, Grossmann M, Bhasin S, Snyder PJ, Ellenberg SS, Travison TG, Brock GB, Gianatti EJ, van der Schouw YT, Emmelot-Vonk MH, Giltay EJ, Hackett G, Ramachandran S, Svartberg J, Hildreth KL, Antonic KG, Tenover JL, Tan HM, Ho Chee Kong C, Tan WS, Marks LS, Ross RJ, Schwartz RS, Manson P, Roberts SA, Skovsager Andersen M, Velling Magnussen L, Aceves-Martins M, Gillies K, Hernández R, Oliver N, Dhillo WS, Bhattacharya S, Brazzelli M, Jayasena CN. Symptomatic benefits of testosterone treatment in patient subgroups: a systematic review, individual participant data meta-analysis, and aggregate data meta-analysis. Lancet Healthy Longev 2023; 4:e561-e572. [PMID: 37804846 DOI: 10.1016/s2666-7568(23)00169-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 03/24/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Testosterone replacement therapy is known to improve sexual function in men younger than 40 years with pathological hypogonadism. However, the extent to which testosterone alleviates sexual dysfunction in older men and men with obesity is unclear, despite the fact that testosterone is being increasingly prescribed to these patient populations. We aimed to evaluate whether subgroups of men with low testosterone derive any symptomatic benefit from testosterone treatment. METHODS We did a systematic review and meta-analysis to evaluate characteristics associated with symptomatic benefit of testosterone treatment versus placebo in men aged 18 years and older with a baseline serum total testosterone concentration of less than 12 nmol/L. We searched major electronic databases (MEDLINE, Embase, Science Citation Index, and the Cochrane Central Register of Controlled Trials) and clinical trial registries for reports published in English between Jan 1, 1992, and Aug 27, 2018. Anonymised individual participant data were requested from the investigators of all identified trials. Primary (cardiovascular) outcomes from this analysis have been published previously. In this report, we present the secondary outcomes of sexual function, quality of life, and psychological outcomes at 12 months. We did a one-stage individual participant data meta-analysis with a random-effects linear regression model, and a two-stage meta-analysis integrating individual participant data with aggregated data from studies that did not provide individual participant data. This study is registered with PROSPERO, CRD42018111005. FINDINGS 9871 citations were identified through database searches. After exclusion of duplicates and publications not meeting inclusion criteria, 225 full texts were assessed for inclusion, of which 109 publications reporting 35 primary studies (with a total 5601 participants) were included. Of these, 17 trials provided individual participant data (3431 participants; median age 67 years [IQR 60-72]; 3281 [97%] of 3380 aged ≥40 years) Compared with placebo, testosterone treatment increased 15-item International Index of Erectile Function (IIEF-15) total score (mean difference 5·52 [95% CI 3·95-7·10]; τ2=1·17; n=1412) and IIEF-15 erectile function subscore (2·14 [1·40-2·89]; τ2=0·64; n=1436), reaching the minimal clinically important difference for mild erectile dysfunction. These effects were not found to be dependent on participant age, obesity, presence of diabetes, or baseline serum total testosterone. However, absolute IIEF-15 scores reached during testosterone treatment were subject to thresholds in patient age and baseline serum total testosterone. Testosterone significantly improved Aging Males' Symptoms score, and some 12-item or 36-item Short Form Survey quality of life subscores compared with placebo, but it did not significantly improve psychological symptoms (measured by Beck Depression Inventory). INTERPRETATION In men aged 40 years or older with baseline serum testosterone of less than 12 nmol/L, short-to-medium-term testosterone treatment could provide clinically meaningful treatment for mild erectile dysfunction, irrespective of patient age, obesity, or degree of low testosterone. However, due to more severe baseline symptoms, the absolute level of sexual function reached during testosterone treatment might be lower in older men and men with obesity. FUNDING National Institute for Health and Care Research Health Technology Assessment Programme.
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Affiliation(s)
- Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Translational & Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Frederick Wu
- Division of Diabetes, Endocrinology & Gastroenterology, University of Manchester, Manchester, UK
| | - Mathis Grossmann
- University of Melbourne Austin Health, Heidelberg, VIC, Australia
| | | | - Peter J Snyder
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Gerald B Brock
- Department of Surgery, Western University and Omega Fertility Center, London, ON, Canada
| | - Emily J Gianatti
- Department of Endocrinology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Marielle H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Erik J Giltay
- Department of Psychiatry, Leiden University Medical Centre, Leiden, Netherlands
| | - Geoff Hackett
- School of Health and Life Sciences, Aston University, Birmingham, UK
| | | | - Johan Svartberg
- Division of Internal Medicine, Section of Endocrinology, University Hospital of North Norway, Tromsø, Norway; Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kerry L Hildreth
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kristina Groti Antonic
- Department of Endocrinology, University Medical Centre, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Joyce Lisa Tenover
- Geriatric Medicine, VA Palo Alto Health Care System, Palo Alto, CA, USA; School of Medicine, Stanford University, Stanford, CA, USA
| | - Hui Meng Tan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Wei Shen Tan
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Leonard S Marks
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Robert S Schwartz
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | | | | | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Nick Oliver
- Faculty of Medicine, Imperial College London, London, UK
| | | | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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5
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O'Brien K, Feng R, Sieber F, Marcantonio ER, Tierney A, Magaziner J, Carson JL, Dillane D, Sessler DI, Menio D, Ayad S, Stone T, Papp S, Schwenk ES, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Hoeft MA, Karlawish J, Mehta S, Donegan DJ, Horan A, Ellenberg SS, Neuman MD. Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial. Alzheimers Dement 2023; 19:4008-4019. [PMID: 37170754 DOI: 10.1002/alz.13132] [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: 10/10/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.
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Affiliation(s)
- Kyra O'Brien
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, USA
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Diane Menio
- Center for Advocacy for the Rights and Interests of the Elderly, Philadelphia, Pennsylvania, USA
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Trevor Stone
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Steven Papp
- Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa, Canada
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York, USA
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York, USA
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Barry Perlman
- Department of Internal Medicine, Peacehealth Medical Group, Springfield, Oregon, USA
| | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Mark A Hoeft
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Jason Karlawish
- Department of Internal Medicine, Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Samir Mehta
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Derek J Donegan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Annamarie Horan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Internal Medicine, Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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6
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DeMets DL, Zarin DA, Rockhold F, Ellenberg SS, Fleming T, Wittes J. Bringing data monitoring committee charters into the sunlight. Clin Trials 2023; 20:447-451. [PMID: 37231737 DOI: 10.1177/17407745231169499] [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] [Indexed: 05/27/2023]
Abstract
Clinical trials investigating novel or high risk interventions, or studying vulnerable participants, often use a data monitoring committee to oversee the progress of the trial. The data monitoring committee serves both an ethical and a scientific function, by protecting the interests of trial participants while ensuring the integrity of the trial results. A data monitoring committee charter, which typically describes the procedures by which data monitoring committees operate, contains details about the data monitoring committee's organizational structure, membership, meeting frequency, sequential monitoring guidelines, and the overall contents of data monitoring committee reports for interim review. These charters, however, are generally not reviewed by outside entities and are rarely publicly available. The result is that a key component of trial oversight remains in the dark. We recommend that ClinicalTrials.gov modify its system to allow uploading of data monitoring committee charters, as is already possible for other important study documents and that clinical trialists take advantage of this opportunity to voluntarily upload the data monitoring committee charter for trials that have one. The resulting cache of publicly available data monitoring committee charters should provide important insights for those interested in a particular trial, as well as for meta-researchers who wish to understand and potentially improve how this important component of trial oversight is actually being applied.
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Affiliation(s)
| | - Deborah A Zarin
- The MRCT Center of Brigham and Women's Hospital and Harvard, Cambridge, MA, USA
| | - Frank Rockhold
- Duke Clinical Research Institute/Duke University, Durham, NC, USA
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7
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Ellenberg SS, Ellenberg JH. Proceedings of the University of Pennsylvania 14th annual conference on statistical issues in clinical trials: Subgroup analysis in randomized clinical trials-Challenges and opportunities. Clin Trials 2023:17407745231173007. [PMID: 37203142 DOI: 10.1177/17407745231173007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas H Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Hunsberger S, Ellenberg SS, Joffe S, Babiker A, Fix A, Griffin MR, Kalil J, Levine MM, Makgoba MW, Moore RH, Tsiatis AA, Whitley R. Monitoring Multiple U.S. Government-Supported Covid-19 Vaccine Trials. NEJM Evid 2023; 2:EVIDctcs2200301. [PMID: 38320019 DOI: 10.1056/evidctcs2200301] [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] [Indexed: 02/08/2024]
Abstract
Monitoring U.S. Government-Supported Covid-19 Vaccine TrialsOperation Warp Speed was a partnership created to accelerate the development of Covid-19 vaccines. The National Institutes of Health oversaw one data and safety monitoring board to review/monitor all Operation Warp Speed trials. This article describes the challenges faced in monitoring these trials and provides ideas for future similar endeavors.
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Affiliation(s)
- Sally Hunsberger
- National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Susan S Ellenberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Steven Joffe
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Abdel Babiker
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Alan Fix
- Center for Vaccine Innovation and Access, PATH, Washington, D.C
| | | | - Jorge Kalil
- Faculdade de Medicina, Universidade de São Paulo, São Paulo
| | | | | | - Reneé H Moore
- Dornsife School of Public Health, Drexel University, Philadelphia
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9
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Baim-Lance A, Ferreira KB, Cohen HJ, Ellenberg SS, Kuchel GA, Ritchie C, Sachs GA, Kitzman D, Morrison RS, Siu A. Improving the Approach to Defining, Classifying, Reporting and Monitoring Adverse Events in Seriously Ill Older Adults: Recommendations from a Multi-stakeholder Convening. J Gen Intern Med 2023; 38:399-405. [PMID: 35581446 PMCID: PMC9905384 DOI: 10.1007/s11606-022-07646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinical trials are needed to study topics relevant to older adults with serious illness. Investigators conducting clinical trials with this population are challenged by how to appropriately define, classify, report, and monitor serious and non-serious adverse events (SAEs/AEs), given that some traditionally reported AEs (pressure ulcers, delirium) and SAEs (death, hospitalization) are common in persons with serious illness, and may be consistent with their goals of care. OBJECTIVES A multi-stakeholder group convened to establish greater clarity on and new approaches to address this critical issue. PARTICIPANTS Thirty-two study investigators, members of regulatory and sponsor agencies, and patient stakeholders took part. APPROACH The group met virtually four times and, using a collaborative approach, conducted a survey, select interviews, and reviewed regulatory guidance to collectively define the problem and identify a new approach. RESULTS SAE/AE challenges fell into two areas: (1) definitions and classifications, including (a) implausible relationships, (b) misalignment with patient-centered care goals, and (c) well-known associations, and (2) reporting and monitoring, including (a) limited guidance, (b) inconsistent standards across regulators, and (c) Data Safety Monitoring Board (DSMB) member knowledge gaps. Problems largely reflected practice norms rather than regulatory requirements that already support context-specific and aggregate reporting. Approaches can be improved by adopting principles that better align strategies for addressing adverse events with the type of intervention being tested, favoring routine and aggregate over expedited reporting, and prioritizing how SAE/AEs relate to patient-centered care goals. Reporting plans and decisions should follow an algorithm underpinned by these principles. CONCLUSIONS Adoption of the proposed approach-and supporting it with education and better alignment with regulatory guidance and procedures-could improve the quality and efficiency of clinical trials' safety involving older adults with serious illness and other vulnerable populations.
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Affiliation(s)
- Abigail Baim-Lance
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA.
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA.
| | - Katelyn B Ferreira
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut, Farmington, CT, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine and the Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dalane Kitzman
- Department of Internal Medicine: Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA
| | - Albert Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA
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10
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Neuman MD, Ellenberg SS, Carson JL, Sieber FE. Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery. Ann Intern Med 2023; 176:eL220367. [PMID: 36645898 DOI: 10.7326/l22-0367] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Mark D Neuman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Susan S Ellenberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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11
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Longini IM, Yang Y, Fleming TR, Muñoz-Fontela C, Wang R, Ellenberg SS, Qian G, Halloran ME, Nason M, Gruttola VD, Mulangu S, Huang Y, Donnelly CA, Henao Restrepo AM. A platform trial design for preventive vaccines against Marburg virus and other emerging infectious disease threats. Clin Trials 2022; 19:647-654. [PMID: 35866633 PMCID: PMC9679315 DOI: 10.1177/17407745221110880] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The threat of a possible Marburg virus disease outbreak in Central and Western Africa is growing. While no Marburg virus vaccines are currently available for use, several candidates are in the pipeline. Building on knowledge and experiences in the designs of vaccine efficacy trials against other pathogens, including SARS-CoV-2, we develop designs of randomized Phase 3 vaccine efficacy trials for Marburg virus vaccines. METHODS A core protocol approach will be used, allowing multiple vaccine candidates to be tested against controls. The primary objective of the trial will be to evaluate the effect of each vaccine on the rate of virologically confirmed Marburg virus disease, although Marburg infection assessed via seroconversion could be the primary objective in some cases. The overall trial design will be a mixture of individually and cluster-randomized designs, with individual randomization done whenever possible. Clusters will consist of either contacts and contacts of contacts of index cases, that is, ring vaccination, or other transmission units. RESULTS The primary efficacy endpoint will be analysed as a time-to-event outcome. A vaccine will be considered successful if its estimated efficacy is greater than 50% and has sufficient precision to rule out that true efficacy is less than 30%. This will require approximately 150 total endpoints, that is, cases of confirmed Marburg virus disease, per vaccine/comparator combination. Interim analyses will be conducted after 50 and after 100 events. Statistical analysis of the trial will be blended across the different types of designs. Under the assumption of a 6-month attack rate of 1% of the participants in the placebo arm for both the individually and cluster-randomized populations, the most likely sample size is about 20,000 participants per arm. CONCLUSION This event-driven design takes into the account the potentially sporadic spread of Marburg virus. The proposed trial design may be applicable for other pathogens against which effective vaccines are not yet available.
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Affiliation(s)
- Ira M Longini
- Department of Biostatistics, University of Florida, Gainesville, FL, USA,Ira M Longini, Department of Biostatistics, University of Florida, Gainesville, FL 32611, USA.
| | - Yang Yang
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - César Muñoz-Fontela
- Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany,German Center for Infection Research, DZIF, Partner site Hamburg, Hamburg, Germany
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA,Department of Biostatistics, Harvard University, Boston, MA, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - George Qian
- London School of Hygiene & Tropical Medicine, London, UK
| | - M Elizabeth Halloran
- Department of Biostatistics, University of Washington, Seattle, WA, USA,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Martha Nason
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases (NIAID/NIH), Bethesda, MD, USA
| | | | - Sabue Mulangu
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo
| | - Yunda Huang
- London School of Hygiene & Tropical Medicine, London, UK
| | - Christl A Donnelly
- Department of Statistics, University of Oxford, Oxford, UK,Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Ellenberg SS, Shaw PA. Early Termination of Clinical Trials for Futility - Considerations for a Data and Safety Monitoring Board. NEJM Evid 2022; 1:EVIDctw2100020. [PMID: 38319261 DOI: 10.1056/evidctw2100020] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Early Termination of Clinical Trials for FutilityClinical trials may be stopped for futility if there is little or no chance of demonstrating the hoped-for effect. Reasons include evidence of no treatment effect, substantial missing data that would unacceptably undermine trial conclusions, or event rates too low to support meaningful comparisons. This review examines issues faced by DSMBs in such settings.
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Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Pamela A Shaw
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle
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13
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Neuman MD, Feng R, Ellenberg SS, Sieber F, Sessler DI, Magaziner J, Elkassabany N, Schwenk ES, Dillane D, Marcantonio ER, Menio D, Ayad S, Hassan M, Stone T, Papp S, Donegan D, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Hoeft MA, Tierney A, Gaskins LJ, Horan AD, Brown T, Dattilo J, Carson JL, Looke T, Bent S, Franco-Mora A, Hedrick P, Newbern M, Tadros R, Pealer K, Vlassakov K, Buckley C, Gavin L, Gorbatov S, Gosnell J, Steen T, Vafai A, Zeballos J, Hruslinski J, Cardenas L, Berry A, Getchell J, Quercetti N, Bajracharya G, Billow D, Bloomfield M, Cuko E, Elyaderani MK, Hampton R, Honar H, Khoshknabi D, Kim D, Krahe D, Lew MM, Maheshwer CB, Niazi A, Saha P, Salih A, de Swart RJ, Volio A, Bolkus K, DeAngelis M, Dodson G, Gerritsen J, McEniry B, Mitrev L, Kwofie MK, Belliveau A, Bonazza F, Lloyd V, Panek I, Dabiri J, Chavez C, Craig J, Davidson T, Dietrichs C, Fleetwood C, Foley M, Getto C, Hailes S, Hermes S, Hooper A, Koener G, Kohls K, Law L, Lipp A, Losey A, Nelson W, Nieto M, Rogers P, Rutman S, Scales G, Sebastian B, Stanciu T, Lobel G, Giampiccolo M, Herman D, Kaufman M, Murphy B, Pau C, Puzio T, Veselsky M, Apostle K, Boyer D, Fan BC, Lee S, Lemke M, Merchant R, Moola F, Payne K, Perey B, Viskontas D, Poler M, D'Antonio P, O'Neill G, Abdullah A, Fish-Fuhrmann J, Giska M, Fidkowski C, Guthrie ST, Hakeos W, Hayes L, Hoegler J, Nowak K, Beck J, Cuff J, Gaski G, Haaser S, Holzman M, Malekzadeh AS, Ramsey L, Schulman J, Schwartzbach C, Azefor T, Davani A, Jaberi M, Masear C, Haider SB, Chungu C, Ebrahimi A, Fikry K, Marcantonio A, Shelvan A, Sanders D, Clarke C, Lawendy A, Schwartz G, Garg M, Kim J, Caruci J, Commeh E, Cuevas R, Cuff G, Franco L, Furgiuele D, Giuca M, Allman M, Barzideh O, Cossaro J, D'Arduini A, Farhi A, Gould J, Kafel J, Patel A, Peller A, Reshef H, Safur M, Toscano F, Tedore T, Akerman M, Brumberger E, Clark S, Friedlander R, Jegarl A, Lane J, Lyden JP, Mehta N, Murrell MT, Painter N, Ricci W, Sbrollini K, Sharma R, Steel PAD, Steinkamp M, Weinberg R, Wellman DS, Nader A, Fitzgerald P, Ritz M, Bryson G, Craig A, Farhat C, Gammon B, Gofton W, Harris N, Lalonde K, Liew A, Meulenkamp B, Sonnenburg K, Wai E, Wilkin G, Troxell K, Alderfer ME, Brannen J, Cupitt C, Gerhart S, McLin R, Sheidy J, Yurick K, Chen F, Dragert K, Kiss G, Malveaux H, McCloskey D, Mellender S, Mungekar SS, Noveck H, Sagebien C, Biby L, McKelvy G, Richards A, Abola R, Ayala B, Halper D, Mavarez A, Rizwan S, Choi S, Awad I, Flynn B, Henry P, Jenkinson R, Kaustov L, Lappin E, McHardy P, Singh A, Donnelly J, Gonzalez M, Haydel C, Livelsberger J, Pazionis T, Slattery B, Vazquez-Trejo M, Baratta J, Cirullo M, Deiling B, Deschamps L, Glick M, Katz D, Krieg J, Lessin J, Mojica J, Torjman M, Jin R, Salpeter MJ, Powell M, Simmons J, Lawson P, Kukreja P, Graves S, Sturdivant A, Bryant A, Crump SJ, Verrier M, Green J, Menon M, Applegate R, Arias A, Pineiro N, Uppington J, Wolinsky P, Gunnett A, Hagen J, Harris S, Hollen K, Holloway B, Horodyski MB, Pogue T, Ramani R, Smith C, Woods A, Warrick M, Flynn K, Mongan P, Ranganath Y, Fernholz S, Ingersoll-Weng E, Marian A, Seering M, Sibenaller Z, Stout L, Wagner A, Walter A, Wong C, Orwig D, Goud M, Helker C, Mezenghie L, Montgomery B, Preston P, Schwartz JS, Weber R, Fleisher LA, Mehta S, Stephens-Shields AJ, Dinh C, Chelly JE, Goel S, Goncz W, Kawabe T, Khetarpal S, Monroe A, Shick V, Breidenstein M, Dominick T, Friend A, Mathews D, Lennertz R, Sanders R, Akere H, Balweg T, Bo A, Doro C, Goodspeed D, Lang G, Parker M, Rettammel A, Roth M, White M, Whiting P, Allen BFS, Baker T, Craven D, McEvoy M, Turnbo T, Kates S, Morgan M, Willoughby T, Weigel W, Auyong D, Fox E, Welsh T, Cusson B, Dobson S, Edwards C, Harris L, Henshaw D, Johnson K, McKinney G, Miller S, Reynolds J, Segal BS, Turner J, VanEenenaam D, Weller R, Lei J, Treggiari M, Akhtar S, Blessing M, Johnson C, Kampp M, Kunze K, O'Connor M, Looke T, Tadros R, Vlassakov K, Cardenas L, Bolkus K, Mitrev L, Kwofie MK, Dabiri J, Lobel G, Poler M, Giska M, Sanders D, Schwartz G, Giuca M, Tedore T, Nader A, Bryson G, Troxell K, Kiss G, Choi S, Powell M, Applegate R, Warrick M, Ranganath Y, Chelly JE, Lennertz R, Sanders R, Allen BFS, Kates S, Weigel W, Li J, Wijeysundera DN, Kheterpal S, Moore RH, Smith AK, Tosi LL, Looke T, Mehta S, Fleisher L, Hruslinski J, Ramsey L, Langlois C, Mezenghie L, Montgomery B, Oduwole S, Rose T. Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial. Ann Intern Med 2022; 175:952-960. [PMID: 35696684 DOI: 10.7326/m22-0320] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING 46 U.S. and Canadian hospitals. PARTICIPANTS Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION Spinal or general anesthesia. MEASUREMENTS Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION Missing outcome data and multiple outcomes assessed. CONCLUSION Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.F., S.S.E.)
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.F., S.S.E.)
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland (F.S.)
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland (J.M.)
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (E.S.S.)
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada (D. Dillane)
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.R.M.)
| | - Diane Menio
- Center for Advocacy for the Rights and Interests of the Elderly, Philadelphia, Pennsylvania (D.M.)
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Manal Hassan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Trevor Stone
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (T.S.)
| | - Steven Papp
- Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada (S.P.)
| | - Derek Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (D. Donegan)
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York (M.M.)
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina (J.D.J.)
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (C.L.)
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts (B.S.)
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York (S. Azim)
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia (R.H.)
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada (K.C.)
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut (R.S.)
| | - Barry Perlman
- Oregon Health and Science University, Portland, Oregon (B.P.)
| | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida (J.S.)
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania (E.H.)
| | - Mark A Hoeft
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont (M.A.H.)
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - Lakisha J Gaskins
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Annamarie D Horan
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.D.H.)
| | - Trina Brown
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - James Dattilo
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.L.C.)
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Ellenberg SS, Ellenberg JH. Proceedings of the University of Pennsylvania 13th annual conference on statistical issues in clinical trials: Cluster randomized clinical trials-Challenges and opportunities. Clin Trials 2022; 19:351-352. [PMID: 35678598 DOI: 10.1177/17407745221100226] [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: 11/15/2022]
Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas H Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Kleykamp BA, Dworkin RH, Turk DC, Bhagwagar Z, Cowan P, Eccleston C, Ellenberg SS, Evans SR, Farrar JT, Freeman RL, Garrison LP, Gewandter JS, Goli V, Iyengar S, Jadad AR, Jensen MP, Junor R, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, McDermott MP, Mease PJ, O'Connor AB, Patel KV, Raja SN, Rowbotham MC, Sampaio C, Singh JA, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Benefit-risk assessment and reporting in clinical trials of chronic pain treatments: IMMPACT recommendations. Pain 2022; 163:1006-1018. [PMID: 34510135 PMCID: PMC8904641 DOI: 10.1097/j.pain.0000000000002475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.
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Affiliation(s)
- Bethea A Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, CT, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | | | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Roy L Freeman
- Harvard Medical School, Center for Autonomic and Peripheral Nerve Disorders, Boston, MA, United States
| | - Louis P Garrison
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Veeraindar Goli
- Pfizer, Inc, New York, NY, United States. Dr. Goli is now with the Emeritus Professor, Duke University School of Medicine, Durham, NC, United States
| | - Smriti Iyengar
- Division of Translational Research, NINDS, NIH, Rockville, MD, United States
| | - Alejandro R Jadad
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Beati, Inc, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Wayland, MA, United States
| | | | | | - Dmitri Lissin
- DURECT Corporation, Cupertino, CA, United States. Dr. Lissin is now woth the Scilex Pharmaceuticals, Inc., San Diego, CA, United States
| | - John D Markman
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Philip J Mease
- Division of Rheumatology Research, Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael C Rowbotham
- Department of Anesthesia, UCSF School of Medicine, Research Institute, CPMC Sutter Health, San Francisco, CA, United States
| | - Cristina Sampaio
- Clinical Pharmacology Lab, Faculdade de Medicina de Lisboa, University Lisbon, Lisbon, Portugal
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, United States
- Department of Medicine at the School of Medicine, University of Alabama (UAB) at Birmingham, Birmingham, AL, United States
- Department of Epidemiology at the UAB School of Public Health, Birmingham, AL, United States
| | - Ilona Steigerwald
- Chief Medical Officer SVP Neumentum, Inc, Morristown NJ, United States
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto CA, United States
| | - Leslie A Tive
- Department of Biopharmaceuticals, Pfizer, Inc, New York, NY, United States
| | | | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, United States
| | - Hilary D Wilson
- Patient Affairs and Engagement, Boehringer Ingelheim, Ridgefield, CT, United States
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Shaw PA, Yang JB, Mowery DL, Schriver ER, Mahoney KB, Bar KJ, Ellenberg SS. Determinants of hospital outcomes for patients with COVID-19 in the University of Pennsylvania Health System. PLoS One 2022; 17:e0268528. [PMID: 35588434 PMCID: PMC9119468 DOI: 10.1371/journal.pone.0268528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/02/2022] [Indexed: 11/30/2022] Open
Abstract
There is growing evidence that racial and ethnic minorities bear a disproportionate burden from COVID-19. Temporal changes in the pandemic epidemiology and diversity in the clinical course require careful study to identify determinants of poor outcomes. We analyzed 6255 hospitalized individuals with PCR-confirmed SARS-CoV-2 infection from one of 5 hospitals in the University of Pennsylvania Health System between March 2020 and March 2021, using electronic health records to assess risk factors and outcomes through 8 weeks post-admission. Discharge, readmission and mortality outcomes were analyzed in a multi-state model with multivariable Cox models for each transition. Mortality varied markedly over time, with cumulative incidence (95% CI) 30 days post-admission of 19.1% (16.9, 21.3) in March-April 2020, 5.7% (4.2, 7.5) in July-October 2020 and 10.5% (9.1,12.0) in January-March 2021; 26% of deaths occurred after discharge. Average age (SD) at admission varied from 62.7 (17.6) to 54.8 (19.9) to 60.5 (18.1); mechanical ventilation use declined from 21.3% to 9-11%. Compared to Caucasian, Black race was associated with more severe disease at admission, higher rates of co-morbidities and residing in a low-income zip code. Between-race risk differences in mortality risk diminished in multivariable models; while admitting hospital, increasing age, admission early in the pandemic, and severe disease and low blood pressure at admission were associated with increased mortality hazard. Hispanic ethnicity was associated with fewer baseline co-morbidities and lower mortality hazard (0.57, 95% CI: 0.37, .087). Multi-state modeling allows for a unified framework to analyze multiple outcomes throughout the disease course. Morbidity and mortality for hospitalized COVID-19 patients varied over time but post-discharge mortality remained non-trivial. Black race was associated with more risk factors for morbidity and with treatment at hospitals with lower mortality. Multivariable models suggest there are not between-race differences in outcomes. Future work is needed to better understand the identified between-hospital differences in mortality.
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Affiliation(s)
- Pamela A. Shaw
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jasper B. Yang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Danielle L. Mowery
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Emily R. Schriver
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kevin B. Mahoney
- Office of the Chief Executive Officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States of America
| | - Katharine J. Bar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Susan S. Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Stephens-Shields AJ, Snyder PJ, Ellenberg SS, Taylor L, Bhasin S. Relation of Testosterone, Dihydrotestosterone, and Estradiol With Changes in Outcomes Measures in the Testosterone Trials. J Clin Endocrinol Metab 2022; 107:1257-1269. [PMID: 35041751 PMCID: PMC9016457 DOI: 10.1210/clinem/dgac028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 09/20/2021] [Indexed: 01/21/2023]
Abstract
CONTEXT Many effects of testosterone are mediated through dihydrotestosterone (DHT) and estradiol. OBJECTIVE To determine the relative contributions of each hormone to the observed effects of testosterone treatment in older men with hypogonadism. METHODS Using data from the Testosterone Trials, we assessed the association of changes in total testosterone, estradiol, and DHT levels over 12 months of testosterone treatment with hemoglobin, high-density lipoprotein (HDL) cholesterol, volumetric bone mineral density (vBMD) of lumbar spine, sexual desire, and prostate-specific antigen (PSA). We used random forests to model the associations of predicted mean changes in outcomes with change in each hormone at low, mean, or high change in the other 2 hormones. Stepwise regression models were run to confirm the findings of random forests. RESULT Predicted increases in hemoglobin and sexual desire were greater with larger increases in estradiol and were larger with high change in DHT compared with low change in DHT. Greater increases in estradiol were associated with larger decreases in HDL cholesterol; this association did not vary according to changes in DHT or testosterone. Change in vBMD was most robustly associated with change in estradiol and was greater with high change in testosterone and DHT. There was no consistent relation between change in PSA and change in any hormone. CONCLUSION Change in estradiol level was the best predictor not only of the change in vBMD and sexual desire but also of the changes in hemoglobin and HDL cholesterol. Consideration of testosterone, estradiol, and DHT together offers a superior prediction of treatment response in older hypogonadal men than testosterone alone.
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Affiliation(s)
- Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Peter J Snyder
- Division of Endocrinology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Lynne Taylor
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Shalender Bhasin
- Research Program in Men’s Health: Aging and Metabolism, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: Shalender Bhasin, MB, BS, Research Program in Men’s Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA.
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18
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Neuman MD, Feng R, Carson JL, Gaskins LJ, Dillane D, Sessler DI, Sieber F, Magaziner J, Marcantonio ER, Mehta S, Menio D, Ayad S, Stone T, Papp S, Schwenk ES, Elkassabany N, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes RA, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Hoeft MA, Giska M, Ranganath Y, Tedore T, Choi S, Li J, Kwofie MK, Nader A, Sanders RD, Allen BFS, Vlassakov K, Kates S, Fleisher LA, Dattilo J, Tierney A, Stephens-Shields AJ, Ellenberg SS. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med 2021; 385:2025-2035. [PMID: 34623788 DOI: 10.1056/nejmoa2113514] [Citation(s) in RCA: 166] [Impact Index Per Article: 55.3] [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: 12/13/2022]
Abstract
BACKGROUND The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).
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Affiliation(s)
- Mark D Neuman
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Rui Feng
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Jeffrey L Carson
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Lakisha J Gaskins
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Derek Dillane
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Daniel I Sessler
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Frederick Sieber
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Jay Magaziner
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Edward R Marcantonio
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Samir Mehta
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Diane Menio
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Sabry Ayad
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Trevor Stone
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Steven Papp
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Eric S Schwenk
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Nabil Elkassabany
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Mitchell Marshall
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - J Douglas Jaffe
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Charles Luke
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Balram Sharma
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Syed Azim
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Robert A Hymes
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Ki-Jinn Chin
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Richard Sheppard
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Barry Perlman
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Joshua Sappenfield
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Ellen Hauck
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Mark A Hoeft
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Mark Giska
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Yatish Ranganath
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Tiffany Tedore
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Stephen Choi
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Jinlei Li
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - M Kwesi Kwofie
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Antoun Nader
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Robert D Sanders
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Brian F S Allen
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Kamen Vlassakov
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Stephen Kates
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Lee A Fleisher
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - James Dattilo
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Ann Tierney
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Alisa J Stephens-Shields
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
| | - Susan S Ellenberg
- From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.)
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Cauley JA, Ellenberg SS, Schwartz AV, Ensrud KE, Keaveny TM, Snyder PJ. Effect of testosterone treatment on the trabecular bone score in older men with low serum testosterone. Osteoporos Int 2021; 32:2371-2375. [PMID: 34080044 PMCID: PMC8563386 DOI: 10.1007/s00198-021-06022-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 01/22/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
UNLABELLED The trabecular bone score (TBS) is an indirect measure of vertebral bone microarchitecture. Our objective was to examine the effect of testosterone treatment on TBS. One hundred and ninety-seven hypogonadal men were randomized to testosterone or placebo. After 12 months, there was no difference in the changes in TBS by randomized group. INTRODUCTION In the Bone Trial of the Testosterone Trials, testosterone treatment increased trabecular volumetric bone mineral density (vBMD) and increased estimated bone strength as determined by finite element analysis. The trabecular bone score (TBS) is an indirect measure of vertebral bone microarchitecture. TBS predicts fracture independent of lumbar spine areal (a) BMD. The objective of this study was to examine the effect of testosterone treatment on TBS compared to its effects on vBMD and aBMD. METHODS Two hundred and eleven men were enrolled in the Bone Trial of the Testosterone Trials. Of these, 197 men had 2 repeat TBS and vBMD measurements; 105 men were allocated to receive testosterone, and 92 men to placebo for 1 year. TBS, aBMD, and vBMD were assessed at baseline and month 12. RESULTS There was no difference in the percent change in TBS by randomized group: 1.6% (95% confidence intervals (CI) 0.2-3.9) in the testosterone group and 1.4% (95% CI -0.2, 3.1) in the placebo group. In contrast, vBMD increased by 6% (95% CI 4.5-7.5) in the testosterone group compared to 0.4% (95% CI -1.65-0.88) in the placebo groups. CONCLUSIONS TBS is not clinically useful in monitoring the 1-year effect of testosterone treatment on bone structure in older hypogonadal men.
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Affiliation(s)
- J A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, A533, Pittsburgh, PA, 15261, USA.
| | - S S Ellenberg
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - A V Schwartz
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - K E Ensrud
- Division of Epidemiology and Community Health, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - T M Keaveny
- Departments of Mechanical Engineering and Bioengineering, University of California, Berkeley, Berkeley, CA, USA
| | - P J Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Morris
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Ellenberg SS, Morris JS. AIDS and COVID: A tale of two pandemics and the role of statisticians. Stat Med 2021; 40:2499-2510. [PMID: 33963579 PMCID: PMC8206852 DOI: 10.1002/sim.8936] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/20/2020] [Revised: 01/26/2021] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
The world has experienced three global pandemics over the last half-century: HIV/AIDS, H1N1, and COVID-19. HIV/AIDS and COVID-19 are still with us and have wrought extensive havoc worldwide. There are many differences between these two infections and their global impacts, but one thing they have in common is the mobilization of scientific resources to both understand the infection and develop ways to combat it. As was the case with HIV, statisticians have been in the forefront of scientists working to understand transmission dynamics and the natural history of infection, determine prognostic factors for severe disease, and develop optimal study designs to assess therapeutics and vaccines.
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Affiliation(s)
- Susan S. Ellenberg
- Department of Biostatistics, Epidemiology and InformaticsPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jeffrey S. Morris
- Department of Biostatistics, Epidemiology and InformaticsPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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22
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Joffe S, Babiker A, Ellenberg SS, Fix A, Griffin MR, Hunsberger S, Kalil J, Levine MM, Makgoba MW, Moore RH, Tsiatis AA, Whitley R. Data and Safety Monitoring of COVID-19 Vaccine Clinical Trials. J Infect Dis 2021; 224:1995-2000. [PMID: 34008027 PMCID: PMC8240876 DOI: 10.1093/infdis/jiab263] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/13/2021] [Indexed: 12/02/2022] Open
Abstract
To speed the development of vaccines against SARS-CoV-2, the United States Federal Government has funded multiple phase 3 trials of candidate vaccines. A single 11-member data and safety monitoring board (DSMB) monitors all government-funded trials to ensure coordinated oversight, promote harmonized designs, and allow shared insights related to safety across trials. DSMB reviews encompass 3 domains: (1) the conduct of trials, including overall and subgroup accrual and data quality and completeness; (2) safety, including individual events of concern and comparisons by randomized group; and (3) interim analyses of efficacy when event-driven milestones are met. Challenges have included the scale and pace of the trials, the frequency of safety events related to the combined enrollment of over 100 000 participants, many of whom are older adults or have comorbid conditions that place them at independent risk of serious health events, and the politicized environment in which the trials have taken place.
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Affiliation(s)
- Steven Joffe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Abdel Babiker
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Alan Fix
- Center for Vaccine Innovation and Access, PATH, Washington, DC, United States
| | | | - Sally Hunsberger
- National Institute of Allergy and Infectious Disease, Rockville, MD, United States
| | - Jorge Kalil
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Myron M Levine
- University of Maryland School of Medicine, Baltimore, MD, United States
| | - Malegapuru W Makgoba
- Health Ombudsman, Office of Health Standards and Compliance, Pretoria, Republic of South Africa
| | - Reneé H Moore
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | | | - Richard Whitley
- University of Alabama at Birmingham, Birmingham, AL, United States
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Abstract
Within the field of randomized clinical trials (RCTs), the randomized double-blind placebo-controlled clinical trial is considered the most efficient means of simultaneously assessing the efficacy and safety of a medical therapy in a single trial. While many RCTs are conducted without blinding (open label), it is rare to encounter a blinded trial that does not randomize its subjects. Clinical trials for chronic liver diseases have adopted many of the practices set forth by RCTs in other chronic diseases, but blinding has often been difficult to properly implement. This review examines the rationale for blinding, common challenges to successful blinding, different mechanisms of unintentional unblinding in clinical trials for viral hepatitis and nonalcoholic steatohepatitis, and recommendations for blinding and design in future trials of treatments for liver disease.
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Affiliation(s)
- Vivian Ortiz
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Huang J, Cai Y, Du J, Li R, Ellenberg SS, Hennessy S, Tao C, Chen Y. Monitoring vaccine safety by studying temporal variation of adverse events using vaccine adverse event reporting system. Ann Appl Stat 2021. [DOI: 10.1214/20-aoas1393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jing Huang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Yi Cai
- AT&T Chief Data Office, AT&T Services, Inc
| | - Jingcheng Du
- School of Biomedical Informatics, University of Texas Health Science Center at Houston
| | - Ruosha Li
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston
| | - Susan S. Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Cui Tao
- School of Biomedical Informatics, University of Texas Health Science Center at Houston
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
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25
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Luo C, Jiang Y, Du J, Tong J, Huang J, Lo Re V, Ellenberg SS, Poland GA, Tao C, Chen Y. Prediction of post-vaccination Guillain-Barré syndrome using data from a passive surveillance system. Pharmacoepidemiol Drug Saf 2021; 30:602-609. [PMID: 33533072 PMCID: PMC8014460 DOI: 10.1002/pds.5196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/11/2021] [Indexed: 01/21/2023]
Abstract
Purpose Severe adverse events (AEs), such as Guillain‐Barré syndrome (GBS) occur rarely after influenza vaccination. We identify highly associated AEs with GBS and develop prediction models for GBS using the US Vaccine Adverse Event Reporting System (VAERS) reports following trivalent influenza vaccination (FLU3). Methods This study analyzed 80 059 reports from the US VAERS between 1990 and 2017. Several AEs were identified as highly associated with GBS and were used to develop the prediction model. Some common and mild AEs that were suspected to be underreported when GBS occurred simultaneously were removed from the final model. The analyses were validated using European influenza vaccine AEs data from EudraVigilance. Results Of the 80 059 reports, 1185 (1.5%) were annotated as GBS related. Twenty‐four AEs were identified as having strong association with GBS. The full prediction model, using age, sex, and all 24 AEs achieved an area under the receiver operating characteristic (ROC) curve (AUC) of 85.4% (90% CI: [83.8%, 86.9%]). After excluding the nine (e.g., pruritus, rash, injection site pain) likely underreported AEs, the final AUC became 77.5% (90% CI: [75.5%, 79.6%]). Two hundred and one (0.25%) reports were predicted as of high risk of GBS (predicted probability >25%) and 84 actually developed GBS. Conclusion The prediction performance demonstrated the potential of developing risk‐prediction models utilizing the VAERS cohort. Excluding the likely underreported AEs sacrificed some prediction power but made the model more interpretable and feasible. The high absolute risk of even a small number of AE combinations suggests the promise of GBS prediction within the VAERS dataset.
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Affiliation(s)
- Chongliang Luo
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ying Jiang
- Department of Neurology and Multiple Sclerosis Research Center, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingcheng Du
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jiayi Tong
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jing Huang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory A Poland
- Mayo Clinic Vaccine Research Group, Mayo Clinic, Rochester, Minnesota, USA
| | - Cui Tao
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Krause PR, Fleming TR, Longini IM, Peto R, Beral V, Bhargava B, Cravioto A, Cramer JP, Ellenberg SS, Figueroa JP, Halloran E, Henao-Restrepo AM, Ryan MJ, Levine MM, Nason M, Nohynek HM, Plotkin S, Rees H, Singh JA, Swaminathan S. Placebo-Controlled Trials of Covid-19 Vaccines - Why We Still Need Them. N Engl J Med 2021; 384:e2. [PMID: 33264543 DOI: 10.1056/nejmp2033538] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Philip R Krause
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Thomas R Fleming
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Ira M Longini
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Richard Peto
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Valerie Beral
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Balram Bhargava
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Alejandro Cravioto
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Jakob P Cramer
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Susan S Ellenberg
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - J Peter Figueroa
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Elizabeth Halloran
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Ana M Henao-Restrepo
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Michael J Ryan
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Myron M Levine
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Martha Nason
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Hanna M Nohynek
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Stanley Plotkin
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Helen Rees
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Jerome A Singh
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
| | - Soumya Swaminathan
- The affiliations of the members of the WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation are the Office of Vaccines Research and Review, Food and Drug Administration, Silver Spring (P.R.K.), the School of Medicine, University of Maryland (M.M.L.), and Johns Hopkins University (S.P.), Baltimore, and the National Institute of Allergy and Infectious Diseases, Bethesda (M.N.) - all in Maryland; the Department of Biostatistics (T.R.F.), Fred Hutchinson Cancer Research Center (T.R.F., E.H.), University of Washington, Seattle; the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (R.P., V.B.); the Indian Council of Medical Research, New Delhi (B.B.); the Faculty of Medicine of the Universidad Nacional Autónoma de México, Mexico City (A.C.); the Coalition for Epidemic Preparedness Innovations, London (J.P.C.); the University of Pennsylvania, Philadelphia (S.S.E., S.P.); the University of the West Indies, Kingston, Jamaica (J.P.F.); the World Health Organization, Geneva (A.M.H.-R., M.J.R., S.S.); the Department of Health Security, Finnish Institute for Health and Welfare, Helsinki (H.M.N.);and the Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg (H.R.), and the Centre for the AIDS Programme of Research in South Africa, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (J.S.) - both in South Africa
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DeMets DL, Fleming TR, Ellenberg SS. Monitoring clinical trials in infectious diseases. J Allergy Infect Dis 2021; 2:29-32. [PMID: 35005713 PMCID: PMC8740779 DOI: 10.46439/allergy.2.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Krause PR, Fleming TR, Ellenberg SS, Henao-Restrepo AM. Maintaining confidentiality of emerging results in COVID-19 vaccine trials is essential. Lancet 2020; 396:1611-1613. [PMID: 33125926 PMCID: PMC7834563 DOI: 10.1016/s0140-6736(20)32259-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Philip R Krause
- Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Thomas R Fleming
- University of Washington, Fred Hutchinson Cancer Centre, Seattle, WA, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Stephens-Shields AJ, Farrar JT, Ellenberg SS, Storer TW, Gill TM, Basaria S, Pahor M, Cauley JA, Ensrud KE, Preston P, Cella D, Snyder PJ, Bhasin S. Clinically Important Differences for Mobility Measures Derived from the Testosterone Trials. J Am Geriatr Soc 2020; 69:517-523. [PMID: 33210287 DOI: 10.1111/jgs.16942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/22/2020] [Accepted: 10/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Accurate estimates of clinically important difference (CID) are required for interpreting the clinical importance of treatments to improve physical function, but CID estimates vary in different disease populations. We determined the CID for two common measures of walking ability in mobility-limited older men. DESIGN Longitudinal, multisite placebo-controlled trial. SETTING/PARTICIPANTS Men enrolled in the Testosterone Trials who had self-reported mobility limitation and gait speed less than 1.2 m/second (n = 429). Testosterone- and placebo-allocated participants were combined for this study. RESULTS Mean changes from baseline, adjusting for time-in-intervention and site, were 29.6, 13.2, 12.5, -2.4, and -32.6 m for 6MWD, and 15.4, 7.2, 2.1, -3.4, and -7.2 for PF10 in men who reported their mobility was "very/much better," "little better," "no change," "little worse," or "much worse," respectively. CID estimates using regression, ROC, and eCDF varied from 5.0-29.6 m for 6MWD, and 5.0-15.2 points for PF10. CONCLUSION CID estimates vary by the population studied and by the method and precision of measurement. Increases of 16 to 30 m for 6MWD and 5 to 15 points for PF10 over 12 months appear to be clinically meaningful in mobility-limited, older hypogonadal men. These CID estimates may be useful in the design of efficacy trials of therapies to improve physical function.
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Affiliation(s)
- Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John T Farrar
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas W Storer
- Research Program in Men's Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas M Gill
- Section of Geriatric Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shehzad Basaria
- Research Program in Men's Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marco Pahor
- Department of Aging & Geriatric Research, University of Florida, Gainesville, Florida, USA
| | - Jane A Cauley
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Kristine E Ensrud
- Department of Medicine, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Peter Preston
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J Snyder
- Division of Endocrinology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shalender Bhasin
- Section of Geriatric Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Artz AS, Stephens-Shields AJ, Bhasin S, Ellenberg SS, Cohen HJ, Snyder PJ. Markers of Iron Flux during Testosterone-Mediated Erythropoiesis in Older Men with Unexplained or Iron-Deficiency Anemia. J Clin Endocrinol Metab 2020; 105:5891785. [PMID: 32785689 PMCID: PMC7500468 DOI: 10.1210/clinem/dgaa521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/19/2020] [Accepted: 08/06/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Testosterone treatment of hypogonadal men improves their hemoglobin, but the mechanism is not understood. OBJECTIVE To investigate possible mechanisms by which testosterone stimulates erythropoiesis in hypogonadal older men with unexplained or iron-deficiency anemia. DESIGN The Anemia Trial of The Testosterone Trials, a placebo-controlled study in older, hypogonadal men. SETTING Twelve academic medical centers. PARTICIPANTS A total of 95 hypogonadal men (testosterone < 275 ng/mL) ≥65 years with anemia (hemoglobin < 12.7 g/dL). They were classified as having unexplained (n = 58) or iron deficiency anemia (n = 37). INTERVENTION Testosterone or placebo gel for 1 year. MAIN OUTCOME MEASURES Markers of iron metabolism during the first 3 months of treatment. RESULTS Testosterone replacement significantly (P < 0.001) increased hemoglobin in the 58 men who had unexplained anemia (adjusted mean difference 0.58 g/dL; 95% confidence interval, 0.31-0.85). Testosterone replacement tended to increase hemoglobin in the 37 men who had iron deficiency (0.38 g/dL; -0.19, 0.95), but the response was more variable and not statistically significant (P = 0.19). In men with unexplained anemia, testosterone replacement suppressed hepcidin (-8.2 ng/mL; -13.7, -2.7; P = 0.004) and ferritin (-19.6 µg/L; -32.8, -6.3; P = 0.004), but in men with iron deficiency, testosterone replacement did not. The decrease in hepcidin was moderately correlated with the increase in hemoglobin in the men with unexplained anemia (correlation coefficient -0.35, P = 0.01) but not in those with iron deficiency anemia (correlation coefficient -0.07, P = 0.73). CONCLUSIONS Testosterone replacement of older hypogonadal men with unexplained anemia stimulates erythropoiesis associated with increased iron mobilization. This effect appears to be attenuated by iron deficiency.
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Affiliation(s)
- Andrew S Artz
- City of Hope, Department of Hematology and Hematopoietic Cell Transplantation, Duarte, California
| | - Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shalender Bhasin
- Research Program in Men’s Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harvey J Cohen
- Duke University Medical Center, Center for the Study of Aging, Durham, North Carolina
| | - Peter J Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Correspondence and Reprint Requests: Peter J. Snyder, Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA. E-mail:
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Smith SM, Dworkin RH, Turk DC, McDermott MP, Eccleston C, Farrar JT, Rowbotham MC, Bhagwagar Z, Burke LB, Cowan P, Ellenberg SS, Evans SR, Freeman RL, Garrison LP, Iyengar S, Jadad A, Jensen MP, Junor R, Kamp C, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, Mease PJ, O'Connor AB, Patel KV, Raja SN, Sampaio C, Schoenfeld D, Singh J, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Interpretation of chronic pain clinical trial outcomes: IMMPACT recommended considerations. Pain 2020; 161:2446-2461. [PMID: 32520773 PMCID: PMC7572524 DOI: 10.1097/j.pain.0000000000001952] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [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: 12/21/2022]
Abstract
Interpreting randomized clinical trials (RCTs) is crucial to making decisions regarding the use of analgesic treatments in clinical practice. In this article, we report on an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, the purpose of which was to recommend approaches that facilitate interpretation of analgesic RCTs. We review issues to consider when drawing conclusions from RCTs, as well as common methods for reporting RCT results and the limitations of each method. These issues include the type of trial, study design, statistical analysis methods, magnitude of the estimated beneficial and harmful effects and associated precision, availability of alternative treatments and their benefit-risk profile, clinical importance of the change from baseline both within and between groups, presentation of the outcome data, and the limitations of the approaches used.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P McDermott
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | | | - John T Farrar
- Departments of Epidemiology, Neurology, and Anesthesia, University of Pennsylvania, Philadelphia, PA, United States
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Rallybio, New Haven, CT, United States
| | - Laurie B Burke
- School of Pharmacy, University of Maryland, Baltimore, MD, United States
- LORA Group, LLC, Royal Oak, MD, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Susan S Ellenberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Epidemiology and Biostatistics, The George Washington University, Washington, DC, United States
| | - Roy L Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Louis P Garrison
- Department of Pharmacy, University of Washington, Seattle, WA, United States
| | | | - Alejandro Jadad
- Department of Anesthesia, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Cornelia Kamp
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
- Clinical Materials Services Unit, University of Rochester Medical Center, Rochester, NY, United States
| | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Natick, MA, United States
| | | | | | - Dmitri Lissin
- Scilex Pharmaceuticals, Palo Alto, CA, United States
| | - John D Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Philip J Mease
- Rheumatology Clinical Research, Swedish Medical Center, Seattle, WA, United States
- University of Washington School of Medicine, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cristina Sampaio
- Faculdade Medicinda de Lisboa, Universidade de Lisboa, Lisboa, Portugal
- CHDI Foundation, Princeton, NJ, United States
| | - David Schoenfeld
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Jasvinder Singh
- Departments of Medicine and Epidemiology, University of Alabama at Birmingham School of Medicine, Birmingham, AB, United States
| | | | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, CA, United States
| | | | - Jeffrey Tobias
- Aquila Consulting Group, LLC, Petaluma, CA, United States
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Neuman MD, Kappelman MD, Israel E, Ellenberg SS, Girman C, Robb J, Rabinowitz A, Trontell A. Real-world experiences with generating real-world evidence: Case Studies from PCORI's pragmatic clinical Studies program. Contemp Clin Trials 2020; 98:106171. [PMID: 33038503 DOI: 10.1016/j.cct.2020.106171] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Over the last decade, randomized studies evaluating outcomes of health care interventions conducted in real-world settings-often termed "pragmatic trials"-have come to be seen as an important means of obtaining relevant, actionable evidence to guide health care decisions. Despite extensive writing on methodological considerations in pragmatic trial design, limited information exists regarding the practical and logistical challenges encountered in carrying out rigorous randomized evaluations in highly representative, real-world contexts. METHODS The Patient Centered Outcomes Research Institute (PCORI) convened an expert panel in 2017 to examine common tradeoffs in study design and implementation through 3 "case studies" of in-progress, PCORI-funded pragmatic trials. This paper summarizes the findings of this panel, using the 3 examples to illustrate common implementation challenges encountered in pragmatic trials. RESULTS Investigators aimed to generate highly generalizable findings that could address real-world clinical decisions; however, practical considerations required that each study incorporate traditionally "explanatory" elements to achieve a "fit-for-purpose" approach to design and implementation. Within individual studies, efforts to balance pragmatic versus explanatory perspectives often involved multiple, diverse aspects of trial design and implementation, and the aspects of design and implementation where investigators reported encountering such tradeoffs varied across the three cases we examined. CONCLUSIONS Efforts to generate rigorous evidence that is generalizable to "real-world" practice require continuous and iterative efforts to balance "pragmatic" and "explanatory" perspectives. In each study examined, these tradeoffs were guided both by an overriding effort to maintain pragmatism and practical considerations that varied depending on the research question and study context.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.
| | - Michael D Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina, Chapel Hill, NC, USA
| | - Elliot Israel
- Department of Medicine, Brigham and Women' s Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | | | - Jess Robb
- Patient-Centered Research Institute, Washington, DC, USA
| | | | - Anne Trontell
- Patient-Centered Research Institute, Washington, DC, USA
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Bamat NA, Ekhaguere OA, Zhang L, Flannery DD, Handley SC, Herrick HM, Ellenberg SS. Protocol adherence rates in superiority and noninferiority randomized clinical trials published in high impact medical journals. Clin Trials 2020; 17:552-559. [PMID: 32666826 DOI: 10.1177/1740774520941428] [Citation(s) in RCA: 2] [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] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIMS Noninferiority clinical trials are susceptible to false confirmation of noninferiority when the intention-to-treat principle is applied in the setting of incomplete trial protocol adherence. The risk increases as protocol adherence rates decrease. The objective of this study was to compare protocol adherence and hypothesis confirmation between superiority and noninferiority randomized clinical trials published in three high impact medical journals. We hypothesized that noninferiority trials have lower protocol adherence and greater hypothesis confirmation. METHODS We conducted an observational study using published clinical trial data. We searched PubMed for active control, two-arm parallel group randomized clinical trials published in JAMA: The Journal of the American Medical Association, The New England Journal of Medicine, and The Lancet between 2007 and 2017. The primary exposure was trial type, superiority versus noninferiority, as determined by the hypothesis testing framework of the primary trial outcome. The primary outcome was trial protocol adherence rate, defined as the number of randomized subjects receiving the allocated intervention as described by the trial protocol and followed to primary outcome ascertainment (numerator), over the total number of subjects randomized (denominator). Hypothesis confirmation was defined as affirmation of noninferiority or the alternative hypothesis for noninferiority and superiority trials, respectively. RESULTS Among 120 superiority and 120 noninferiority trials, median and interquartile protocol adherence rates were 91.5 [81.4-96.7] and 89.8 [83.6-95.2], respectively; P = 0.47. Hypothesis confirmation was observed in 107/120 (89.2%) of noninferiority and 64/120 (53.3%) of superiority trials, risk difference (95% confidence interval): 35.8 (25.3-46.3), P < 0.001. CONCLUSION Protocol adherence rates are similar between superiority and noninferiority trials published in three high impact medical journals. Despite this, we observed greater hypothesis confirmation among noninferiority trials. We speculate that publication bias, lenient noninferiority margins and other sources of bias may contribute to this finding. Further study is needed to identify the reasons for this observed difference.
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Affiliation(s)
- Nicolas A Bamat
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Osayame A Ekhaguere
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University, Indianapolis, IN, USA
| | - Lingqiao Zhang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Biosense Webster, Inc., Irvine, CA, USA
| | - Dustin D Flannery
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara C Handley
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heidi M Herrick
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
The first rumblings about a new coronavirus spreading in China were heard in January 2020. By the end of that month, the World Health Organization, recognizing the severity of the disease and the potential for global spread, had declared a public health emergency. By February 2020, cases had been identified in multiple countries, clinical trials of treatments with some biological plausibility had begun in China, and the initial steps of vaccine development were underway. In mid-March, by which time countries around the world were experiencing rapidly increasing numbers of cases and deaths, the World Health Organization categorized the outbreak as a pandemic. This new coronavirus was designated SARS-COV-2 in recognition of its similarity to the coronavirus responsible for the severe acute respiratory syndrome outbreak in 2002–2003. The race is on to develop treatments that can mitigate the severe consequences of infection and vaccines that can prevent infection and/or diminish the severity of disease in those who do get infected. Many challenges face these development efforts. Some are similar to those faced in the past; others are new. The urgency of finding ways to treat, and ultimately prevent, the consequences of this new and potentially deadly infection has led to unprecedented focus on clinical trials.
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Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Shaikh K, Ellenberg SS, Nakanishi R, Snyder PJ, Lee J, Wenger NK, Lewis CE, Swerdloff RS, Preston P, Hamal S, Stephens-Sheilds A, Bhasin S, Cherukuri L, Cauley JA, Crandall JP, Cunningham GR, Ensrud KE, Matsumoto AM, Molich ME, Alla VM, Birudaraju D, Nezarat N, Rai K, Almeida S, Roy SK, Sheikh M, Trad G, Budoff MJ. Biomarkers and Noncalcified Coronary Artery Plaque Progression in Older Men Treated With Testosterone. J Clin Endocrinol Metab 2020; 105:5648063. [PMID: 31784747 PMCID: PMC7209773 DOI: 10.1210/clinem/dgz242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Received: 05/07/2019] [Accepted: 11/29/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Recent results from the Cardiovascular Trial of the Testosterone Trials showed that testosterone treatment of older men with low testosterone was associated with greater progression of noncalcified plaque (NCP). We evaluated the effect of anthropometric measures and cardiovascular biomarkers on plaque progression in individuals in the Testosterone Trial. METHODS The Cardiovascular part of the trial included 170 men aged 65 years or older with low testosterone. Participants received testosterone gel or placebo gel for 12 months. The primary outcome was change in NCP volume from baseline to 12 months, as determined by coronary computed tomography angiography (CCTA). We assayed several markers of cardiovascular risk and analyzed each marker individually in a model as predictive variables and change in NCP as the dependent variable. RESULTS Of 170 enrollees, 138 (73 testosterone, 65 placebo) completed the study and were available for the primary analysis. Of 10 markers evaluated, none showed a significant association with the change in NCP volume, but a significant interaction between treatment assignment and waist-hip ratio (WHR) (P = 0.0014) indicated that this variable impacted the testosterone effect on NCP volume. The statistical model indicated that for every 0.1 change in the WHR, the testosterone-induced 12-month change in NCP volume increased by 26.96 mm3 (95% confidence interval, 7.72-46.20). CONCLUSION Among older men with low testosterone treated for 1 year, greater WHR was associated with greater NCP progression, as measured by CCTA. Other biomarkers and anthropometric measures did not show statistically significant association with plaque progression.
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Affiliation(s)
- Kashif Shaikh
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
- Correspondence: Kashif Shaikh, MD, Advanced Cardiac Imaging Fellow, Division of Cardiology, Harbor UCLA, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California. E-mail:
| | - Susan S Ellenberg
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rine Nakanishi
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Peter J Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Juhwan Lee
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Nanette K Wenger
- Department of Medicine, Division of Cardiology, Emory Heart and Vascular Center Emory University School of Medicine, Atlanta, Georgia
| | - Cora E Lewis
- Division of Preventive Medicine, University of Alabama at Birmingham, Alabama
| | - Ronald S Swerdloff
- Division of Endocrinology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Peter Preston
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sajad Hamal
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Alisa Stephens-Sheilds
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shalender Bhasin
- Department of Family and Preventive Medicine, Division of Epidemiology, University of California, San Diego School of Medicine, La Jolla, California
| | - Lavanya Cherukuri
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Jane A Cauley
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Jill P Crandall
- Divisions of Endocrinology and Geriatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Glenn R Cunningham
- Departments of Medicine and Molecular & Cellular Biology, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine and Baylor St. Luke’s Medical Center, Houston, Texas
| | - Kristine E Ensrud
- Department of Medicine, Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Alvin M Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs, Puget Sound Health System, and Division of Gerontology and Geriatric Medicine, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Mark E Molich
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Venkata M Alla
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
| | - Divya Birudaraju
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Negin Nezarat
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Kelash Rai
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Shone Almeida
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Sion K Roy
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Mohammad Sheikh
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - George Trad
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
| | - Mathew J Budoff
- Division of Cardiology, Lundquist Institute of Biomedical Innovation, Harbor-University of California at Los Angeles Medical Center, Torrance, California
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Ogburn EL, Bierer BE, Brookmeyer R, Choirat C, Dean NE, De Gruttola V, Ellenberg SS, Halloran ME, Hanley DF, Lee JK, Wang R, Scharfstein DO. Aggregating data from COVID-19 trials. Science 2020; 368:1198-1199. [PMID: 32527823 DOI: 10.1126/science.abc8993] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Elizabeth L Ogburn
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
| | - Barbara E Bierer
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Ron Brookmeyer
- Fielding School of Public Health and Department of Biostatistics, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Christine Choirat
- Swiss Data Science Center, ETH Zürich and EPFL, 1015 Lausanne, Switzerland
| | - Natalie E Dean
- Department of Biostatistics, University of Florida, Gainesville, FL 32611, USA
| | - Victor De Gruttola
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics and Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - M Elizabeth Halloran
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.,Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Daniel F Hanley
- Johns Hopkins Institute of Clinical and Translational Research, Baltimore, MD 21202, USA
| | - Joseph K Lee
- Covid-19 Collaboration Platform, Boston, MA 02118, USA
| | - Rui Wang
- Harvard Medical School, Boston, MA 02115, USA.,Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA
| | - Daniel O Scharfstein
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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37
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Ellenberg SS, Ellenberg JH. Proceedings of the University of Pennsylvania 12th annual conference on statistical issues in clinical trials: Electronic health records (EHR) in randomized clinical trials-Challenges and opportunities. Clin Trials 2020; 17:343-345. [PMID: 32522023 DOI: 10.1177/1740774520931112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas H Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Dean NE, Gsell PS, Brookmeyer R, Crawford FW, Donnelly CA, Ellenberg SS, Fleming TR, Halloran ME, Horby P, Jaki T, Krause PR, Longini IM, Mulangu S, Muyembe-Tamfum JJ, Nason MC, Smith PG, Wang R, Henao-Restrepo AM, De Gruttola V. Creating a Framework for Conducting Randomized Clinical Trials during Disease Outbreaks. N Engl J Med 2020; 382:1366-1369. [PMID: 32242365 PMCID: PMC7490833 DOI: 10.1056/nejmsb1905390] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Natalie E Dean
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Pierre-Stéphane Gsell
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Ron Brookmeyer
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Forrest W Crawford
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Christl A Donnelly
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Susan S Ellenberg
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Thomas R Fleming
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - M Elizabeth Halloran
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Peter Horby
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Thomas Jaki
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Philip R Krause
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Ira M Longini
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Sabue Mulangu
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Jean-Jacques Muyembe-Tamfum
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Martha C Nason
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Peter G Smith
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Rui Wang
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Ana M Henao-Restrepo
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
| | - Victor De Gruttola
- From the Department of Biostatistics, University of Florida, Gainesville (N.E.D., I.M.L.); the World Health Organization, Geneva (P.-S.G., A.M.H.-R.); the Department of Biostatistics, University of California, Los Angeles (R.B.); the Department of Biostatistics, Yale University, New Haven, CT (F.W.C.); the Department of Statistics (C.A.D.) and the Centre for Tropical Medicine and Global Health (P.H.), University of Oxford, Oxford, the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London (C.A.D.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (P.G.S.), London, and the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.) - all in the United Kingdom; the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (S.S.E.); the Department of Biostatistics, University of Washington (T.R.F., M.E.H.), and the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center (M.E.H.) - both in Seattle; the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring (P.R.K.), and the Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda (M.C.N.) - both in Maryland; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo (S.M., J.-J.M.-T.); and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute (R.W.), and the Department of Biostatistics, Harvard T.H. Chan School of Public Health (R.W., V.D.G.) - both in Boston
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Evans SR, Bigelow R, Chuang-Stein C, Ellenberg SS, Gallo P, He W, Jiang Q, Rockhold F. Presenting Risks and Benefits: Helping the Data Monitoring Committee Do Its Job. Ann Intern Med 2020; 172:119-125. [PMID: 31739312 DOI: 10.7326/m19-1491] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Indexed: 11/22/2022] Open
Abstract
Data monitoring committees (DMCs), or data and safety monitoring boards, protect clinical trial participants by conducting benefit-risk assessments during the course of a clinical trial. These evaluations may be improved by broader access to data and more effective analyses and presentation. Data monitoring committees should have access to all data, including efficacy data, at each interim review. The DMC reports should include graphical presentations that summarize benefits and harms in efficient ways. Benefit-risk assessments should include summaries that are consistent with the intention-to-treat principle and have a pragmatic focus. This article provides examples of graphical summaries that integrate benefits and harms, and proposes that such summaries become standard in DMC reports.
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Affiliation(s)
- Scott R Evans
- George Washington University, Rockville, Maryland (S.R.E.)
| | - Robert Bigelow
- Duke Clinical Research Institute, Durham, North Carolina (R.B.)
| | | | | | - Paul Gallo
- Novartis Pharmaceuticals, East Hanover, New Jersey (P.G.)
| | - Weili He
- AbbVie, North Chicago, Illinois (W.H.)
| | - Qi Jiang
- Seattle Genetics, Bothell, Washington (Q.J.)
| | - Frank Rockhold
- Duke University Medical Center, Durham, North Carolina (F.R.)
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Cunningham GR, Ellenberg SS, Bhasin S, Matsumoto AM, Parsons JK, Preston P, Cauley JA, Gill TM, Swerdloff RS, Wang C, Ensrud KE, Lewis CE, Pahor M, Crandall JP, Molitch ME, Cifelli D, Basaria S, Diem SJ, Stephens-Shields AJ, Hou X, Snyder PJ. Prostate-Specific Antigen Levels During Testosterone Treatment of Hypogonadal Older Men: Data from a Controlled Trial. J Clin Endocrinol Metab 2019; 104:6238-6246. [PMID: 31504596 PMCID: PMC6823728 DOI: 10.1210/jc.2019-00806] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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] [Received: 04/03/2019] [Accepted: 07/17/2019] [Indexed: 12/18/2022]
Abstract
CONTEXT Prostate-specific antigen (PSA) changes during testosterone treatment of older hypogonadal men have not been rigorously evaluated. DESIGN Double-blinded, placebo-controlled trial. SETTING Twelve US academic medical centers. PARTICIPANTS Seven hundred ninety hypogonadal men ≥65 years of age with average testosterone levels ≤275 ng/dL. Men at high risk for prostate cancer were excluded. INTERVENTIONS Testosterone or placebo gel for 12 months. MAIN OUTCOMES Percentile changes in PSA during testosterone treatment of 12 months. RESULTS Testosterone treatment that increased testosterone levels from 232 ± 63 ng/dL to midnormal was associated with a small but substantially greater increase (P < 0.001) in PSA levels than placebo treatment. Serum PSA levels increased from 1.14 ± 0.86 ng/mL (mean ± SD) at baseline by 0.47 ± 1.1 ng/mL at 12 months in the testosterone group and from 1.25 ± 0.86 ng/mL by 0.06 ± 0.72 ng/mL in the placebo group. Five percent of men treated with testosterone had an increase ≥1.7 ng/mL and 2.5% of men had an increase of ≥3.4 ng/mL. A confirmed absolute PSA >4.0 ng/mL at 12 months was observed in 1.9% of men in the testosterone group and 0.3% in the placebo group. Four men were diagnosed with prostate cancer; two were Gleason 8. CONCLUSIONS When hypogonadal older men with normal baseline PSA are treated with testosterone, 5% had an increase in PSA ≥1.7 ng/mL, and 2.5% had an increase ≥3.4 ng/mL.
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Affiliation(s)
- Glenn R Cunningham
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Baylor St. Luke's Medical Center, Houston, Texas
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shalender Bhasin
- Research Program in Men’s Health: Aging and Metabolism, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alvin M Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gerontology & Geriatric Medicine, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - J Kellogg Parsons
- Department of Urology, Moores Comprehensive Cancer Center, University of California San Diego, San Diego, California
| | - Peter Preston
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas M Gill
- Division of Geriatric Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ronald S Swerdloff
- Division of Endocrinology, Harbor-University of California at Los Angeles Medical Center, Torrance, California
- Los Angeles Biomedical Research Institute, Torrance, California
| | - Christina Wang
- Division of Endocrinology, Harbor-University of California at Los Angeles Medical Center, Torrance, California
- Los Angeles Biomedical Research Institute, Torrance, California
| | - Kristine E Ensrud
- Department of Medicine, Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Cora E Lewis
- Department of Epidemiology, School of Public Health at UAB, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marco Pahor
- Department of Aging & Geriatric Research, University of Florida, Gainesville, Florida
| | - Jill P Crandall
- Divisions of Endocrinology and Geriatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Denise Cifelli
- Center for Clinical Epidemiology & Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shehzad Basaria
- Research Program in Men’s Health: Aging and Metabolism, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susan J Diem
- Department of Medicine, Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoling Hou
- Center for Clinical Epidemiology & Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter J Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Correspondence and Reprint Requests: Peter J. Snyder, MD, Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104. E-mail:
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Ellenberg SS, Keusch GT, Babiker AG, Edwards KM, Lewis RJ, Lundgren JD, Wells CD, Wabwire-Mangen F, McAdam KPWJ. Rigorous Clinical Trial Design in Public Health Emergencies Is Essential. Clin Infect Dis 2019; 66:1467-1469. [PMID: 29177461 DOI: 10.1093/cid/cix1032] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/18/2017] [Indexed: 12/18/2022] Open
Abstract
Randomized clinical trials are the most reliable approaches to evaluating the effects of new treatments and vaccines. During the 2014-2015 West African Ebola epidemic, many argued that such trials were neither ethical nor feasible in an environment of limited health infrastructure and severe disease with a high fatality rate. Consensus among the numerous organizations providing help to the affected areas was never achieved, resulting in fragmented collaboration, delayed study initiation, and ultimately failure to provide definitive evidence on the efficacy of treatments and vaccines. Randomized trials were in fact approved by local ethics boards and initiated, demonstrating that randomized trials, even in such difficult circumstances, are feasible. Improved planning and collaboration among research and humanitarian organizations, and affected communities, in the interepidemic periods are needed to ensure that questions regarding the efficacy of vaccines and treatments can be definitively answered during future public health emergencies.
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Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gerald T Keusch
- Departments of Medicine and Global Health, Boston University Schools of Medicine and Public Health, Massachusetts
| | - Abdel G Babiker
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, University of California, Los Angeles, California
| | - Jens D Lundgren
- Department of Infectious Diseases, University of Copenhagen, Denmark
| | - Charles D Wells
- Infectious Diseases Unit, Sanofi-US, Bridgewater, New Jersey
| | - Fred Wabwire-Mangen
- Department of Epidemiology, Makerere University School of Public Health, Kampala, Uganda
| | - Keith P W J McAdam
- Department of Clinical and Tropical Medicine, London School of Hygiene and Tropical Medicine, United Kingdom
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42
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Kawut SM, Ellenberg SS, Krowka MJ, Goldberg D, Vargas H, Koch D, Sharkoski T, Al-Naamani N, Fox A, Brown R, Levitsky J, Oh JK, Lin G, Song N, Mottram C, Doyle MF, Kaplan DE, Gupta S, Fallon MB. Sorafenib in Hepatopulmonary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Liver Transpl 2019; 25:1155-1164. [PMID: 30816637 PMCID: PMC6910867 DOI: 10.1002/lt.25438] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 01/05/2019] [Accepted: 02/10/2019] [Indexed: 12/12/2022]
Abstract
The tyrosine kinase inhibitor sorafenib improves hepatopulmonary syndrome (HPS) in an experimental model. However, the efficacy and adverse effect profile in patients with HPS are unknown. We aimed to determine the effect of sorafenib on the alveolar-arterial oxygen gradient (AaPO2 ) at 3 months in patients with HPS. We performed a randomized, double-blind, placebo-controlled parallel trial of sorafenib in patients with HPS at 7 centers. A total of 28 patients with HPS were randomized to sorafenib 400 mg by mouth daily or a matching placebo in a 1:1 ratio. We found no statistically significant difference in the median change in AaPO2 from baseline to 12 weeks between the patients allocated to sorafenib (4.5 mm Hg; IQR, -3.8 to 7.0 mm Hg) and those allocated to placebo (-2.4 mm Hg; IQR, -4.8 to 8.2 mm Hg; P = 0.70). There was also no difference between the groups in terms of degree of intrapulmonary shunting by contrast echocardiography. Sorafenib significantly reduced circulating levels of angiogenic markers, including vascular endothelial growth factor receptors (P < 0.01) and TIE2-expressing M2 monocytes (P = 0.03), but it reduced the mental component scores of the Short Form 36 (P = 0.04), indicating a worse quality of life. In conclusion, sorafenib did not change the AaPO2 or other disease markers at 3 months in patients with HPS. Alternative antiangiogenic therapies or treatments targeting other pathways should be investigated.
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Affiliation(s)
- Steven M. Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Susan S. Ellenberg
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - David Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hugo Vargas
- Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - David Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Tiffany Sharkoski
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alyson Fox
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Robert Brown
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Joshua Levitsky
- Department of Medicine, Northwestern University, Chicago, IL
| | - Jae K. Oh
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Grace Lin
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nianfu Song
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Carl Mottram
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Margaret F. Doyle
- Department of Laboratory Medicine, University of Vermont School of Medicine, Burlington, VT
| | - David E. Kaplan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Samir Gupta
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Michael B. Fallon
- Department of Medicine, University of Arizona College of Medicine—Phoenix, Phoenix, AZ
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43
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Ellenberg SS, Ellenberg JH. Proceedings of the University of Pennsylvania 11th annual conference on statistical issues in clinical trials: Estimands, missing data and sensitivity analysis. Clin Trials 2019; 16:337-338. [DOI: 10.1177/1740774519853569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas H Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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44
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Dember LM, Lacson E, Brunelli SM, Hsu JY, Cheung AK, Daugirdas JT, Greene T, Kovesdy CP, Miskulin DC, Thadhani RI, Winkelmayer WC, Ellenberg SS, Cifelli D, Madigan R, Young A, Angeletti M, Wingard RL, Kahn C, Nissenson AR, Maddux FW, Abbott KC, Landis JR. The TiME Trial: A Fully Embedded, Cluster-Randomized, Pragmatic Trial of Hemodialysis Session Duration. J Am Soc Nephrol 2019; 30:890-903. [PMID: 31000566 DOI: 10.1681/asn.2018090945] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 02/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Data from clinical trials to inform practice in maintenance hemodialysis are limited. Incorporating randomized trials into dialysis clinical care delivery should help generate practice-guiding evidence, but the feasibility of this approach has not been established. METHODS To develop approaches for embedding trials into routine delivery of maintenance hemodialysis, we performed a cluster-randomized, pragmatic trial demonstration project, the Time to Reduce Mortality in ESRD (TiME) trial, evaluating effects of session duration on mortality (primary outcome) and hospitalization rate. Dialysis facilities randomized to the intervention adopted a default session duration ≥4.25 hours (255 minutes) for incident patients; those randomized to usual care had no trial-driven approach to session duration. Implementation was highly centralized, with no on-site research personnel and complete reliance on clinically acquired data. We used multiple strategies to engage facility personnel and participating patients. RESULTS The trial enrolled 7035 incident patients from 266 dialysis units. We discontinued the trial at a median follow-up of 1.1 years because of an inadequate between-group difference in session duration. For the primary analysis population (participants with estimated body water ≤42.5 L), mean session duration was 216 minutes for the intervention group and 207 minutes for the usual care group. We found no reduction in mortality or hospitalization rate for the intervention versus usual care. CONCLUSIONS Although a highly pragmatic design allowed efficient enrollment, data acquisition, and monitoring, intervention uptake was insufficient to determine whether longer hemodialysis sessions improve outcomes. More effective strategies for engaging clinical personnel and patients are likely required to evaluate clinical trial interventions that are fully embedded in care delivery.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, .,Department of Biostatistics, Epidemiology, and Informatics
| | - Eduardo Lacson
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Tom Greene
- Departments of Population Health Science and Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Dana C Miskulin
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts.,Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Denise Cifelli
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosemary Madigan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Young
- DaVita Clinical Research, Minneapolis, Minnesota
| | - Michael Angeletti
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Rebecca L Wingard
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Christina Kahn
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Allen R Nissenson
- DaVita Kidney Care, El Segundo, California.,David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; and
| | - Franklin W Maddux
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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45
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Giuffrida MA, Brown DC, Ellenberg SS, Farrar JT. Development and psychometric testing of the Canine Owner-Reported Quality of Life questionnaire, an instrument designed to measure quality of life in dogs with cancer. J Am Vet Med Assoc 2019; 252:1073-1083. [PMID: 29641337 DOI: 10.2460/javma.252.9.1073] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe development and initial psychometric testing of an owner-reported questionnaire designed to standardize measurement of general quality of life (QOL) in dogs with cancer. DESIGN Key-informant interviews, questionnaire development, and field trial. SAMPLE Owners of 25 dogs with cancer for item development and pretesting and owners of 90 dogs with cancer for reliability and validity testing. PROCEDURES Standard methods for development and testing of questionnaire instruments intended to measure subjective states were used. Items were generated, selected, scaled, and pretested for content, meaning, and readability. Response items were evaluated with exploratory factor analysis and by assessing internal consistency (Cronbach α) and convergence with global QOL as determined with a visual analog scale. Preliminary tests of stability and responsiveness were performed. RESULTS The final questionnaire-which was named the Canine Owner-Reported Quality of Life (CORQ) questionnaire-contained 17 items related to observable behaviors commonly used by owners to evaluate QOL in their dogs. Several items pertaining to physical symptoms performed poorly and were omitted. The 17 items were assigned to 4 factors-vitality, companionship, pain, and mobility-on the basis of the items they contained. The CORQ questionnaire and its factors had high internal consistency (Cronbach α = 0.68 to 0.90) and moderate to strong correlations (r = 0.49 to 0.71) with global QOL as measured on a visual analog scale. Preliminary testing indicated good test-retest reliability and responsiveness to improvements in overall QOL. CONCLUSIONS AND CLINICAL RELEVANCE The CORQ questionnaire was a valid, reliable owner-reported questionnaire that measured general QOL in dogs with cancer and showed promise as a clinical trial outcome measure for quantifying changes in individual dog QOL occurring in response to cancer treatment and progression.
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46
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Bhasin S, Ellenberg SS, Storer TW, Basaria S, Pahor M, Stephens-Shields AJ, Cauley JA, Ensrud KE, Farrar JT, Cella D, Matsumoto AM, Cunningham GR, Swerdloff RS, Wang C, Lewis CE, Molitch ME, Barrett-Connor E, Crandall JP, Hou X, Preston P, Cifelli D, Snyder PJ, Gill TM. Effect of testosterone replacement on measures of mobility in older men with mobility limitation and low testosterone concentrations: secondary analyses of the Testosterone Trials. Lancet Diabetes Endocrinol 2018; 6:879-890. [PMID: 30366567 PMCID: PMC6816466 DOI: 10.1016/s2213-8587(18)30171-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/10/2018] [Accepted: 05/10/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Physical Function Trial (PFT) was one of seven Testosterone Trials (TTrials), the aim of which was to assess the effect of testosterone on mobility, self-reported physical function, falls, and patient global impression-of-change (PGIC) in older men with low testosterone concentrations, self-reported mobility limitation, and walking speed of less than 1·2 m/s. Using data from the PFT and the overall TTrials study population, we also aimed to identify whether the effect of testosterone on mobility differed according to baseline walking speed, mobility limitation, or other participant-level factors. METHODS The TTrials included 790 men aged 65 years or older and with an average of two total testosterone concentrations below 275 ng/dL (9·5 nmol/L), of whom 390 had mobility limitation and a walking speed below 1·2 m/s and were enrolled in the PFT. Participants were assigned (by minimisation method) to 1% testosterone gel or placebo gel daily for 12 months, with participants and study staff masked to intervention allocation. The primary outcome of the PFT was an increase in 6 min walk test (6MWT) distance of 50 m or more. Here we report data for absolute change in 6MWT distance and physical component of Short Form-36 (PF10), and for PGIC and falls. Data are reported for men enrolled in the PFT and those who were not, and for all men in TTrials; data are also reported according to baseline walking speed and mobility limitation. Analyses were done in a modified intention-to-treat population in all patients who were allocated to treatment, had a baseline assessment, and at least one post-intervention assessment. The TTrials are registered with ClinicalTrials.gov, number NCT00799617. FINDINGS The TTrials took place between April 28, 2011 and June 16, 2014. Of 790 TTrials participants, 395 were allocated to testosterone and 395 to placebo; of the 390 participants enrolled in the PFT, 193 were allocated to testosterone and 197 to placebo. As reported previously, 6MWT distance improved significantly more in the testosterone than in the placebo group among all men in the TTrials, but not in those who were enrolled in the PFT; among TTrials participants not enrolled in the PFT, 6MWT distance improved with a treatment effect of 8·9 m (95% CI 2·2-15·6; p=0·010). As reported previously, PF10 improved more in the testosterone group than in the placebo group in all men in TTrials and in men enrolled in the PFT; among those not enrolled in the PFT, PF10 improved with an effect size of 4·0 (1·5-6·5; p=0·0019). Testosterone-treated men with baseline walking speed of 1·2 m/s or higher had significantly greater improvements in 6MWT distance (treatment effect 14·2 m, 6·5-21·9; p=0·0004) and PF10 (4·9, 2·2-7·7; p=0·0005) than placebo-treated men. Testosterone-treated men reporting mobility limitation showed significantly more improvement in 6MWT distance (7·6 m, 1·0-14·1; p=0·0237) and PF10 (3·6, 1·3-5·9; p=0·0018) than placebo-treated men. Men in the testosterone group were more likely to perceive improvement in their walking ability (PGIC) than men in the placebo group, both for men enrolled in the PFT (effect size 2·21, 1·35-3·63; p=0·0018) and those not enrolled in the PFT (3·01, 1·61-5·63; p=0·0006). Changes in 6MWT distance were significantly associated with changes in testosterone, free testosterone, dihydrotestosterone, and haemoglobin concentrations. Fall frequency during the intervention period was identical in the two treatment groups of the TTrials (103 [27%] of 380 analysed in both groups had at least one fall). INTERPRETATION Testosterone therapy consistently improved self-reported walking ability, modestly improved 6MWT distance (across all TTtrials participants), but did not affect falls. The effect of testosterone on mobility measures were related to baseline gait speed and self-reported mobility limitation, and changes in testosterone and haemoglobin concentrations. FUNDING US National Institute on Aging and AbbVie.
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Affiliation(s)
- Shalender Bhasin
- Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas W Storer
- Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shehzad Basaria
- Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Pahor
- Department of Aging & Geriatric Research, University of Florida, Gainesville, FL, USA
| | - Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kristine E Ensrud
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA; Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - John T Farrar
- Center for Clinical Epidemiology & Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alvin M Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Puget Sound Health Care System, and Division of Gerontology & Geriatric Medicine, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Glenn R Cunningham
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine and Baylor St Luke's Medical Center, Houston, TX, USA
| | - Ronald S Swerdloff
- Division of Endocrinology, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, USA
| | - Christina Wang
- Division of Endocrinology, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, USA
| | - Cora E Lewis
- Division of Preventive Medicine, University of Alabama, Birmingham, AL, USA
| | - Mark E Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth Barrett-Connor
- Department of Internal Medicine and Division of Epidemiology, Department of Family Medicine and Public Health, University of California, San Diego School of Medicine, La Jolla, CA USA
| | - Jill P Crandall
- Divisions of Endocrinology and Geriatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Xiaoling Hou
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Preston
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Denise Cifelli
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter J Snyder
- Division of Endocrinology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas M Gill
- Section of Geriatric Medicine, Yale School of Medicine, New Haven, CT, USA
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Ellenberg SS, Keusch GT, Babiker AG, Edwards KM, Lewis RJ, Lundgren JD, Wells CD, Wabwire-Mangen F, McAdam KPWJ. Reply to Jacob and Colebunders. Clin Infect Dis 2018; 67:985-986. [PMID: 29590323 DOI: 10.1093/cid/ciy250] [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: 11/13/2022] Open
Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gerald T Keusch
- Departments of Medicine and Global Health, Boston University Schools of Medicine and Public Health, Massachusetts
| | - Abdel G Babiker
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Jens D Lundgren
- Department of Infectious Diseases, University of Copenhagen, Denmark
| | - Charles D Wells
- Infectious Diseases Unit, Sanofi-U.S., Bridgewater, New Jersey
| | - Fred Wabwire-Mangen
- Department of Epidemiology, Makerere University School of Public Health, Kampala, Uganda
| | - Keith P W J McAdam
- Department of Clinical and Tropical Medicine, London School of Hygiene and Tropical Medicine, United Kingdom
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48
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Ellenberg SS, Ellenberg JH. Proceedings of the University of Pennsylvania 10th annual conference on statistical issues in clinical trials: Current issues regarding Data and Safety Monitoring Committees in clinical trials. Clin Trials 2018; 15:319-320. [DOI: 10.1177/1740774518781817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas H Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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49
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Affiliation(s)
- Colin B Begg
- 1 Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan S Ellenberg
- 2 Center for Clinical Epidemiology and Biostatistics (CCEB), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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50
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Snyder PJ, Bhasin S, Cunningham GR, Matsumoto AM, Stephens-Shields AJ, Cauley JA, Gill TM, Barrett-Connor E, Swerdloff RS, Wang C, Ensrud KE, Lewis CE, Farrar JT, Cella D, Rosen RC, Pahor M, Crandall JP, Molitch ME, Resnick SM, Budoff M, Mohler ER, Wenger NK, Cohen HJ, Schrier S, Keaveny TM, Kopperdahl D, Lee D, Cifelli D, Ellenberg SS. Lessons From the Testosterone Trials. Endocr Rev 2018; 39. [PMID: 29522088 PMCID: PMC6287281 DOI: 10.1210/er.2017-00234] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [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] [Indexed: 12/11/2022]
Abstract
The Testosterone Trials (TTrials) were a coordinated set of seven placebo-controlled, double-blind trials in 788 men with a mean age of 72 years to determine the efficacy of increasing the testosterone levels of older men with low testosterone. Testosterone treatment increased the median testosterone level from unequivocally low at baseline to midnormal for young men after 3 months and maintained that level until month 12. In the Sexual Function Trial, testosterone increased sexual activity, sexual desire, and erectile function. In the Physical Function Trial, testosterone did not increase the distance walked in 6 minutes in men whose walk speed was slow; however, in all TTrial participants, testosterone did increase the distance walked. In the Vitality Trial, testosterone did not increase energy but slightly improved mood and depressive symptoms. In the Cognitive Function Trial, testosterone did not improve cognitive function. In the Anemia Trial, testosterone increased hemoglobin in both men who had anemia of a known cause and in men with unexplained anemia. In the Bone Trial, testosterone increased volumetric bone mineral density and the estimated strength of the spine and hip. In the Cardiovascular Trial, testosterone increased the coronary artery noncalcified plaque volume as assessed using computed tomographic angiography. Although testosterone was not associated with more cardiovascular or prostate adverse events than placebo, a trial of a much larger number of men for a much longer period would be necessary to determine whether testosterone increases cardiovascular or prostate risk.
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Affiliation(s)
- Peter J Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shalender Bhasin
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Glenn R Cunningham
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine and Baylor St. Luke's Medical Center, Houston, Texas
| | - Alvin M Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Puget Sound Health Care System, and Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane A Cauley
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Thomas M Gill
- Division of Geriatric Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth Barrett-Connor
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California, San Diego, School of Medicine, La Jolla, California
| | - Ronald S Swerdloff
- Division of Endocrinology, Harbor-University of California at Los Angeles Medical Center and Los Angeles Biomedical Research Institute, Torrance, California
| | - Christina Wang
- Division of Endocrinology, Harbor-University of California at Los Angeles Medical Center and Los Angeles Biomedical Research Institute, Torrance, California
| | - Kristine E Ensrud
- Division of Epidemiology and Community Health, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Cora E Lewis
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - John T Farrar
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond C Rosen
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Marco Pahor
- Department of Aging and Geriatric Research, University of Florida, Gainesville, Florida
| | - Jill P Crandall
- Divisions of Endocrinology and Geriatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Susan M Resnick
- Laboratory of Behavioral Neuroscience, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Matthew Budoff
- Division of Cardiology, Harbor-University of California at Los Angeles Medical Center and Los Angeles Biomedical Research Institute, Torrance, California
| | - Emile R Mohler
- Division of Cardiovascular Disease, Section of Vascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nanette K Wenger
- Division of Cardiology, Emory University School of Medicine, Emory Heart and Vascular Center, and Emory Women's Heart Center, Atlanta, Georgia
| | - Harvey Jay Cohen
- Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Stanley Schrier
- Department of Medicine, Stanford University, Stanford, California
| | | | | | - David Lee
- O.N. Diagnostics, LLC, Berkeley, California
| | - Denise Cifelli
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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