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Collier T, Shakur-Still H, Roberts I, Balogun E, Olayemi O, Bello FA, Chaudhri R, Muganyizi P. Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: Statistical analysis plan for the WOMAN-2 trial: an international, randomised, placebo-controlled trial. Gates Open Res 2023; 7:69. [PMID: 37664793 PMCID: PMC10471795 DOI: 10.12688/gatesopenres.14529.2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background: Postpartum haemorrhage (PPH) is responsible for over 50,000 maternal deaths every year. Most of these deaths are in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases surgical bleeding and reduces deaths from bleeding after traumatic injury. When given within three hours of birth, TXA reduces deaths from bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. World-wide, over one-third of pregnant women are anaemic and many are severely anaemic. These women have an increased risk of PPH and are more likely to die if PPH occurs. There is an urgent need to identify ways to prevent severe postpartum bleeding in anaemic women. The WOMAN-2 trial will quantify the effects of TXA on postpartum bleeding in women with anaemia. Results: This statistical analysis plan (version 1.0; dated 22 February 2023) has been written based on information in the WOMAN-2 Trial protocol version 2.0, dated 30 June 2022. The primary outcome of the WOMAN-2 trial is the proportion of women with a clinical diagnosis of primary PPH. Secondary outcomes are maternal blood loss and its consequences (estimated blood loss, haemoglobin, haemodynamic instability, blood transfusion, signs of shock, use of interventions to control bleeding); maternal health and wellbeing (fatigue, headache, dizziness, palpitations, breathlessness, exercise tolerance, ability to care for her baby, health related quality of life, breastfeeding); and other health outcomes (deaths, vascular occlusive events, organ dysfunction, sepsis, side effects, time spent in higher level facility, length of hospital stay, and status of the baby). Conclusions: WOMAN-2 will provide reliable evidence about the effects of TXA in women with anaemia. Registration: WOMAN-2 was prospectively registered at the International Standard Randomised Controlled Trials registry ( ISRCTN62396133) on 07/12/2017 and ClinicalTrials.gov on 23/03/2018 ( NCT03475342).
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Affiliation(s)
- Tim Collier
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Haleema Shakur-Still
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ian Roberts
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Eni Balogun
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Oladapo Olayemi
- College of Medicine, University of Ibadan, Ibadan, 200212, Nigeria
| | | | - Rizwana Chaudhri
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Projestine Muganyizi
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - WOMAN-2 Trial Collaborators
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- College of Medicine, University of Ibadan, Ibadan, 200212, Nigeria
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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2
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Richards T, Miles LF, Clevenger B, Keegan A, Abeysiri S, Rao Baikady R, Besser MW, Browne JP, Klein AA, Macdougall IC, Murphy GJ, Anker SD, Dahly D, Besser M, Browne J, Clevenger B, Kegan A, Klein A, Miles L, MacDougall I, Baikady RR, Dahly D, Bradbury A, Richards T, Burley T, Van Loen S, Anker S, Klein A, MacDougall I, Murphy G, Besser M, Unsworth I, Clayton T, Collier T, Potter K, Abeysiri S, Evans R, Knight R, Swinson R, Van Dyck L, Keidan J, Williamson L, Crook A, Pepper J, Dobson J, Newsome S, Godec T, Dodd M, Richards T, Van Dyck L, Evans R, Abeysiri S, Clevenger B, Butcher A, Swinson R, Collier T, Potter K, Anker S, Kelly J, Morris S, Browne J, Keidan J, Grocott M, Chau M, Knight R, Collier T, Baikady RR, Black E, Lawrence H, Kouthra M, Horner K, Jhanji S, Todman E, Keon‐Cohen Z, Rooms M, Tomlinson J, Bailes I, Walker S, Pirie K, Gerstman M, Kasivisvanathan R, Uren S, Magee D, Eeles A, Anker R, McCanny J, O'Mahony M, Reynolds T, Batley S, Hegarty A, Trundle S, Mazzola F, Tatham K, Balint A, Morrison B, Evans M, Pang CL, Smith L, Wilson C, Sjorin V, Khatri P, Wilson M, Parkinson D, Crosbie J, Dawas K, Smyth D, Bercades G, Ryu J, Reyes A, Martir G, Gallego L, Macklin A, Rocha M, Tam DK, Brealey DD, Dhesi J, Morrison C, Hardwick J, Partridge J, Braude P, Rogerson A, Jahangir N, Thomson C, Biswell L, Cross J, Pritchard F, Mohammed A, Wallace D, Galat MG, Okello J, Symes R, Leon J, Gibbs C, Sanghera S, Dennis A, Kibutu F, Fofie J, Bird S, Alli A, Jackson Y, Albuheissi S, Brain C, Shiridzinomwa C, Ralph C, Wroath B, Hammonds F, Adams B, Faulds J, Staddon S, Hughes T, Saha S, Finney C, Harris C, Mellis C, Johnson L, Riozzi P, Yarnold A, Buchanan F, Hopkins P, Greig L, Noble H, Edwards M, Grocott M, Plumb J, Harvie D, Dushianthan A, Wakatsuki M, Leggett S, Salmon K, Bolger C, Burnish R, Otto J, Rayat G, Golder K, Bartlett P, Bali S, Seaward L, Wadams B, Tyrell B, Collins H, Tantony N, Geale R, Wilson A, Ball D, Lindsey I, Barker D, Thyseen M, Chiam P, Hannaway C, Colling K, Messer C, Verma N, Nasseri M, Poonawala G, Sellars A, Mainali P, Hammond T, Hughes A, O'Hara D, McNeela F, Shillito L, Kotze A, Moriarty C, Wilson J, Davies S, Yates D, Carter J, Redman J, Ma S, Howard K, Redfearn H, Wilcock D, Lowe J, Alexander T, Jose J, Hornzee G, Akbar F, Rey S, Patel A, Coulson S, Saini R, Santipillai J, McCretton T, McCanny J, Chima K, Collins K, Pathmanathan B, Chattersingh A, McLeavy L, Al‐Saadi Z, Patel M, Skampardoni S, Chinnadurai R, Thomas V, Keen A, Pagett K, Keatley C, Howard J, Greenhalgh M, Jenkins S, Gidda R, Watts A, Breaton C, Parker J, Mallett S, James S, Penny L, Chan K, Reeves T, Catterall M, Williams S, Birch J, Hammerton K, Williamson N, Thomas A, Evans M, Mercer L, Horsfield G, Hughes C, Cupitt J, Stoddard E, McNamara H, Birt C, Hardy A, Dennis R, Butcher D, O'Sullivan S, Pope A, Elhanash S, Preston S, Officer H, Stoker A, Moss S, Walker A, Gipson A, Melville J, Bradley‐Potts J, McCormac R, Benson V, Melia K, Fielding J, Guest W, Ford S, Murdoch H, Beames S, Townshend P, Collins K, Glass J, Cartwright B, Altemimi B, Berresford L, Jones C, Kelliher L, de Silva S, Blightman K, Pendry K, Pinto L, Allard S, Taylor L, Chishti A, Scott J, O'Hare D, Lewis M, Hussain Z, Hallett K, Dermody S, Corbett C, Morby L, Hough M, Williams S, Williams P, Horton S, Ashcroft P, Homer A, Lang A, Dawson H, Harrison E, Thompson J, Hariharan V, Goss V, Ravi R, Butt G, Vertue M, Acheson A, Ng O, Bush D, Dickson E, Ward A, Morris S, Taylor A, Casey R, Wilson L, Vimalachandran D, Faulkner M, Jeffrey H, Gabrielle C, Martin S, Bracewell A, Ritzema J, Sproates D, Alexander‐Sefre F, Kubitzek C, Humphreys S, Curtis J, Oats P, Swann S, Holden A, Adam C, Flintoff L, Paoloni C, Bobruk K. The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial. Anaesthesia 2023; 78:320-329. [PMID: 36477695 PMCID: PMC10107684 DOI: 10.1111/anae.15926] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 12/13/2022]
Abstract
In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l-1 ; functional iron deficiency as ferritin 30-100 μg.l-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.
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Affiliation(s)
- T Richards
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia.,Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK
| | - L F Miles
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, VIC, Australia.,Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - B Clevenger
- Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK
| | - A Keegan
- Department of Haematology, PathWest Laboratory Medicine, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - S Abeysiri
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia
| | - R Rao Baikady
- Department of Anaesthesia, The Royal Marsden NHS Foundation Trust, London, UK
| | - M W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - J P Browne
- School of Public Health, University College Cork, Ireland
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - I C Macdougall
- Department of Renal Medicine, King's College Hospital, London, UK
| | - G J Murphy
- Department of Cardiovascular Sciences, University of Leicester, UK
| | - S D Anker
- Department of Cardiology, Berlin Institute of Health Centre for Regenerative Therapies; German Centre for Cardiovascular Research partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - D Dahly
- School of Public Health, University College Cork, Ireland.,Health Research Board Clinical Research Facility, University College Cork, Ireland
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Spirito A, Kastrati A, Moliterno DJ, Baber U, Cao D, Sartori S, Collier T, Gibson CM, Angiolillo DJ, Pocock SJ, Cohen DJ, Escaned J, Sardella G, Dangas G, Mehran R. Impact of different antiplatelet therapy cessation modes on outcomes in patients treated with ticagrelor with or without aspirin after PCI: the twilight-antiplatelet cessation study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1232] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/14/2022] Open
Abstract
Abstract
Background
The Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT) trial showed that a regimen consisting of a 3-month dual antiplatelet therapy (DAPT) followed by ticagrelor monotherapy reduces the rate of bleeding events without increasing ischemic complications compared with standard DAPT [1]. Previous studies, such as Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients (PARIS) demonstrated how deviation or cessation of the prescribed antiplatelet regimen might negatively affect clinical outcomes [2].
Purpose
The proposed analysis aims to assess the impact of different antiplatelet therapy cessation patterns on ischemic and bleeding outcomes in patients treated with ticagrelor with or without aspirin after percutaneous coronary intervention (PCI).
Methods
All 7,119 patients randomized at 3 months post-PCI in the TWILIGHT study will be included. The analyses will be conducted separately in the two treatment arms (ticagrelor plus placebo and ticagrelor plus aspirin). According to the PARIS study definitions and as prespecified in the TWILIGHT trial protocol, the occurrence of the three following antiplatelet cessation modes will be assessed: 1) discontinuation (e.g., caused by intolerable side effects or because of a safety concern); 2) interruption (temporary, <14 days, because of surgical or other invasive procedures); 3) disruption (due to non-compliance or bleeding).
The primary endpoint will be the composite of all-cause death, myocardial infarction (MI), or stroke at 12 months after randomization. The key secondary endpoint will be BARC type 2, 3 or 5 bleeding. Other secondary endpoints will include the components of the primary endpoint, cardiovascular death, definite or probable stent thrombosis and BARC types 3 or 5 bleeding. The number of events will be estimated according to the antiplatelet cessation status before the clinical event. Hazard ratios and 95% confidence intervals will be generated using Cox proportional hazards models including antiplatelet therapy cessation as a time-updated variable. If more than one cessation event occurred during follow-up, the antiplatelet therapy cessation category will change only if the more recent mode is worse than the previous: disruption will have priority over interruption, which in turn will have priority over discontinuation. Patients without cessation events will represent the reference group. All adverse events and episodes of antiplatelet cessation were independently adjudicated.
Results
The results of this analysis will be presented for the first time at ESC 2022.
Conclusion
This prespecified analysis of the TWILIGHT study will show for the first time the impact on clinical outcomes of different antiplatelet therapy cessation modes when a regimen of Ticagrelor with our without aspirin is prescribed after PCI.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Astra Zeneca, United Kingdom
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Affiliation(s)
- A Spirito
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - A Kastrati
- German Heart Center Muenchen Technical University of Munich , Munich , Germany
| | - D J Moliterno
- University of Kentucky, Division of Cardiovascular Medicine, Gill Heart Institute , Lexington , United States of America
| | - U Baber
- University of Oklahoma Health Sciences Center , Oklahoma City , United States of America
| | - D Cao
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - S Sartori
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - T Collier
- London School of Hygiene and Tropical Medicine, Department of Medical Statistics , London , United Kingdom
| | - C M Gibson
- Beth Israel Deaconess Medical Center , Boston , United States of America
| | - D J Angiolillo
- University of Florida College of Medicine , Jacksonville , United States of America
| | - S J Pocock
- London School of Hygiene and Tropical Medicine, Department of Medical Statistics , London , United Kingdom
| | - D J Cohen
- St. Francis Hospital, Department of Cardiology , Roslyn , United States of America
| | - J Escaned
- Complutense University of Madrid, Hospital Clínico San Carlos IDISCC , Madrid , Spain
| | - G Sardella
- Polyclinic Umberto I, Department of Cardiovascular Sciences , Rome , Italy
| | - G Dangas
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - R Mehran
- Icahn School of Medicine at Mount Sinai , New York , United States of America
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Mendieta Badimon G, Mehta S, Baber U, Collier T, Dangas G, Sharma SK, Cohen DJ, Angiolillo D, Briguori C, Escaned J, Gabriel Steg P, Huber K, Michael Gibson C, Pocock S, Mehran R. Effect of aspirin discontinuation according to individualised patient bleeding and ischemic risks after PCI: a TWILIGHT trial sub-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2063] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/13/2022] Open
Abstract
Abstract
Background
The TWILIGHT trial demonstrated a reduction in BARC 2, 3 or 5 (BARC-235) bleeding without an increase in ischemic events at 1-year in high-risk PCI patients randomized to placebo or aspirin (ASA) on a background of ticagrelor 3-months after PCI. However, the effect of ASA discontinuation according to baseline risk of bleeding and ischemic events remain unclear.
Purpose
To a) develop separate models to predict the risk of bleeding and ischemic events, and b) to assess treatment effect of ASA discontinuation across the risk strata.
Methods
Using the TWILIGHT patient database (N=7,119), two multivariable models, one for BARC-235 bleeding and one for CV death, nonfatal MI or nonfatal ischemic stroke (ischemic endpoint) were developed, and their predictive capacity was assessed. The effect of randomized treatment on bleeding and ischemic events across different patient risk-group categories as determined by the risk scores was investigated.
Results
At 1-year, 350 (5.4%) patients experienced a BARC-235 bleeding event and 258 (3.6%) experienced an ischemic event. Independent predictors of BARC-235 included haemoglobin levels at index PCI, proton-pump inhibitor non-use at discharge, age, liver disease and active smoking (c-statistic 0.64). Independent predictors of the ischemic outcome included a positive troponin ACS, prior CABG, diabetes, age, peripheral artery disease, prior PCI, a history of congestive heart failure, active smoking, the level of index PCI complexity, and prior MI (c-statistic 0.71). The risk of a BARC-235 almost doubled between patients in lower versus higher bleeding risk categories (4.3% versus 7.9%) and ischemic risk more than tripled between patients in lower versus higher ischemic risk categories (2.0% versus 7.0%) (see Figure 1). There was no evidence of a differential treatment effect for dual antiplatelet therapy versus ticagrelor monotherapy across the different risk categories of bleeding (interaction P=0.54) and ischemic risk (interaction P=0.95) (Table 1).
Conclusion
Individual patient bleeding and ischemic risks after PCI can both be readily characterised with good discrimination. The effect of ASA discontinuation in preventing bleeding in ticagrelor-treated patients was consistent regardless of baseline bleeding risk. There was no evidence for increased ischemic events with ASA discontinuation according to baseline ischemic risk.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZenecaIcahn School of Medicine at Mount Sinai
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Affiliation(s)
| | - S Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences , Hamilton , Canada
| | - U Baber
- The University of Oklahoma Health Sciences Center, Cardiology , Oklahoma City , United States of America
| | - T Collier
- London School of Hygiene and Tropical Medicine, Medical Statistics , London , United Kingdom
| | - G Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai , New York City , United States of America
| | - S K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai , New York City , United States of America
| | - D J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA & St. Francis Hospital, Roslyn, NY 11576 , New York , United States of America
| | - D Angiolillo
- University of Florida College of Medicine, Cardiology , Jacksonville , United States of America
| | - C Briguori
- Mediterranea Cardiocentro , Naples , Italy
| | - J Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid , Madrid , Spain
| | - P Gabriel Steg
- Université de Paris, AP-HP, Hôpital Bichat, French Alliance for Cardiovascular Trials and INSERM , Paris , France
| | - K Huber
- Wilhelminen Hospital, Sigmund Freud University, Medical Faculty, 3rd Department of Medicine, Cardiology and Intensive Care Medicine , Vienna , Austria
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center & Harvard Medical School, Cardiovascular Medicine , Boston , United States of America
| | - S Pocock
- London School of Hygiene and Tropical Medicine, Medical Statistics , London , United Kingdom
| | - R Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai , New York City , United States of America
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Pirondini L, Gregson J, Owen R, Collier T, Pocock S. Covariate Adjustment in Cardiovascular Randomized Controlled Trials: Its Value, Current Practice, and Need for Improvement. JACC Heart Fail 2022; 10:297-305. [PMID: 35483791 DOI: 10.1016/j.jchf.2022.02.007] [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] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
In randomized controlled trials, patient characteristics are expected to be well balanced between treatment groups; however, adjustment for characteristics that are prognostic can still be beneficial with a modest gain in statistical power. Nevertheless, previous reviews show that many trials use unadjusted analyses. In this article, we review current practice regarding covariate adjustment in cardiovascular trials among all 84 randomized controlled trials relating to cardiovascular disease published in the New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association during 2019. We identify trials in which use of covariate adjustment led to a change in the trial conclusions. By using these trials as case studies, along with data from the CHARM trial and simulation studies, we demonstrate some of the potential benefits and pitfalls of covariate adjustment. We discuss some of the complexities of using covariate adjustment, including how many covariates to choose, how covariates should be modeled, how to handle missing data for baseline covariates, and how adjusted analyses are viewed by regulators. We conclude that contemporary cardiovascular trials do not make best use of covariate adjustment and that more frequent use could lead to improvements in the efficiency of future trials.
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Affiliation(s)
- Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ruth Owen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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6
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Nicolas J, Steg PG, Cao D, Baber U, Sartori S, Zhang Z, Sharma SK, Cohen DJ, Angiolillo DJ, Collier T, Escaned J, Gil R, Beerkens F, Džavík V, Henry TD, Huber K, Kornowski R, Ohman EM, Krucoff MW, Kunadian V, Pocock SJ, Gibson CM, Dangas GD, Mehran R. TICAGRELOR MONOTHERAPY AFTER PCI ACROSS THE SPECTRUM OF HIGH-RISK PATIENTS: A DEEP DIVE INTO THE TWILIGHT TRIAL. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01626-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cao D, Baber U, Dangas G, Sartori S, Zhongjie Z, Giustino G, Angiolillo DJ, Mehta S, Gibson CM, Sardella G, Sharma SK, Shlofmitz R, Collier T, Pocock S, Mehran R. Ticagrelor monotherapy after percutaneous coronary intervention in patients with concomitant diabetes mellitus and chronic kidney disease: a TWILIGHT substudy. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2117] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/13/2022] Open
Abstract
Abstract
Background
Diabetes mellitus (DM) and chronic kidney disease (CKD) are established risk factors for cardiovascular events, with patients presenting both conditions being at extremely high risk. P2Y12 inhibitor monotherapy with ticagrelor after a short course of dual antiplatelet therapy has emerged as a bleeding avoidance strategy for high-risk patients undergoing percutaneous coronary intervention (PCI).
Purpose
To investigate ischemic and bleeding outcomes associated with ticagrelor monotherapy versus ticagrelor plus aspirin according to the presence or absence of CKD and DM.
Methods
The TWILIGHT trial enrolled patients undergoing PCI with a drug-eluting stent who fulfilled at least one clinical and one angiographic high-risk criterion. Both DM and CKD (estimated glomerular filtration rate <60 mL/min/1.73m2) were clinical study entry criteria. Following 3 months of ticagrelor plus aspirin, patients who had been adherent to treatment and free from major adverse events were randomly assigned to either aspirin or placebo in addition to ticagrelor for 1 year. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction, or stroke. Net adverse clinical events (NACE) were defined as BARC type 3 or 5 bleeding, all-cause death, myocardial infarction, or stroke.
Results
Of the 6273 patients included in the analysis, 8.0% had both CKD and DM (DM+/CKD+), 8.9% had CKD only (DM-/CKD+), 29.0% had DM only (DM+/CKD-), and 52.1% had neither CKD nor DM (DM-/CKD-). At 1-year follow-up, there was a progressive increase in the rates of bleeding and ischemic events according to DM and CKD status (Figure 1). Ticagrelor plus placebo reduced the primary bleeding endpoint as compared with ticagrelor plus aspirin across all study groups, including DM+/CKD+ patients (4.7% vs. 8.7%; HR 0.52, 95% CI 0.25–1.07), with no evidence of heterogeneity (p-interaction=0.68). Similar treatment effects of ticagrelor monotherapy were observed for major BARC type 3 or 5 bleeding (p-interaction=0.17), with DM+/CKD+ patients showing the greatest absolute risk reduction (0.9% vs. 5.1%; HR 0.16, 95% CI 0.04–0.72). The key secondary endpoint was not significantly different between treatment arms across study groups, with the exception of a reduced risk in DM+/CKD- patients receiving ticagrelor monotherapy (p-interaction=0.033). A similar pattern in the DM+/CKD- group was observed for NACE (p-interaction=0.030) (Figure 2).
Conclusions
Among high-risk patients undergoing PCI, ticagrelor monotherapy reduced the risk of clinically relevant and major bleeding without a significant increase in ischemic events as compared with ticagrelor plus aspirin, irrespective of the presence of DM and CKD. Furthermore, ticagrelor monotherapy seemed to be associated with a more favourable net benefit in patients with DM without CKD.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Investigator-initiated grant from AstraZeneca Figure 1. Event rates according to DM/CKD statusFigure 2. Effects of ticagrelor monotherapy
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Affiliation(s)
- D Cao
- Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - U Baber
- University of Oklahoma Health Sciences Center, Oklahoma City, United States of America
| | - G Dangas
- Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - S Sartori
- Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Z Zhongjie
- Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - G Giustino
- Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - D J Angiolillo
- University of Florida College of Medicine, Jacksonville, United States of America
| | - S Mehta
- McMaster University, Hamilton, Canada
| | - C M Gibson
- Beth Israel Deaconess Medical Center, Boston, United States of America
| | - G Sardella
- Umberto I Polyclinic of Rome, Rome, Italy
| | - S K Sharma
- Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - R Shlofmitz
- St. Francis Hospital, Roslyn, United States of America
| | - T Collier
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - R Mehran
- Icahn School of Medicine at Mount Sinai, New York, United States of America
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Richards T, Baikady RR, Clevenger B, Butcher A, Abeysiri S, Chau M, Swinson R, Collier T, Dodd M, Dyck LV, Macdougall I, Murphy G, Browne J, Bradbury A, Klein A. Preoperative intravenous iron for anaemia in elective major open abdominal surgery: the PREVENTT RCT. Health Technol Assess 2021; 25:1-58. [PMID: 33632377 DOI: 10.3310/hta25110] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Anaemia affects 30-50% of patients before they undergo major surgery. Preoperative anaemia is associated with increased need for blood transfusion, postoperative complications and worse patient outcomes after surgery. International guidelines support the use of intravenous iron to correct anaemia in patients before surgery. However, the use of preoperative intravenous iron for patient benefit has not been assessed in the setting of a formal clinical trial. OBJECTIVES To assess if intravenous iron given to patients with anaemia before major abdominal surgery is beneficial by reducing transfusion rates, postoperative complications, hospital stay and re-admission to hospital, and improving quality of life outcomes. DESIGN A multicentre, double-blinded, randomised, controlled, Phase III clinical trial, with 1 : 1 randomisation comparing placebo (normal saline) with intravenous iron (intravenous ferric carboxymaltose 1000 mg). Randomisation and treatment allocation were by a secure web-based service. SETTING The study was conducted across 46 hospitals in England, Scotland and Wales between September 2013 and September 2018. PARTICIPANTS Patients aged > 18 years, undergoing elective major open abdominal surgery, with anaemia [Hb level of > 90 g/l and < 120 g/l (female patients) and < 130 g/l (male patients)] who could undergo randomisation and treatment 10-42 days before their operation. INTERVENTION Double-blinded study comparing placebo of normal saline with 1000 mg of ferric carboxymaltose administered 10-42 days prior to surgery. MAIN OUTCOME MEASURES Co-primary end points were risk of blood transfusion or death at 30 days postoperatively, and rate of blood transfusions at 30 days post operation. RESULTS A total of 487 patients were randomised (243 given placebo and 244 given intravenous iron), of whom 474 completed the trial and provided data for the analysis of the co-primary end points. The use of intravenous iron increased preoperative Hb levels (mean difference 4.7 g/l, 95% confidence interval 2.7 to 6.8 g/l; p < 0.0001), but had no effect compared with placebo on risk of blood transfusion or death (risk ratio 1.03, 95% confidence interval 0.78 to 1.37; p = 0.84; absolute risk difference +0.8%, 95% confidence interval -7.3% to 9.0%), or rates of blood transfusion (rate ratio 0.98, 95% confidence interval 0.68 to 1.43; p = 0.93; absolute rate difference 0.00, 95% confidence interval -0.14 to 0.15). There was no difference in postoperative complications or hospital stay. The intravenous iron group had higher Hb levels at the 8-week follow-up (difference in mean 10.7 g/l, 95% confidence interval 7.8 to 13.7 g/l; p < 0.0001). There were a total of 71 re-admissions to hospital for postoperative complications in the placebo group, compared with 38 re-admissions in the intravenous iron group (rate ratio 0.54, 95% confidence interval 0.34 to 0.85; p = 0.009). There were no differences between the groups in terms of mortality (two per group at 30 days post operation) or in any of the prespecified safety end points or serious adverse events. CONCLUSIONS In patients with anaemia prior to elective major abdominal surgery, there was no benefit from giving intravenous iron before the operation. FUTURE WORK The impact of iron repletion on recovery from postoperative anaemia, and the association with reduced re-admission to hospital for complications, should be investigated. LIMITATIONS In the preoperative intravenous iron to treat anaemia in major surgery (PREVENTT) trial, all patients included had anaemia and only 20% had their anaemia corrected before surgery. The definition and causality of iron deficiency in this setting is not clear. TRIAL REGISTRATION Current Controlled Trials ISRCTN67322816 and ClinicalTrials.gov NCT01692418. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25 No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Toby Richards
- Division of Surgery, University of Western Australia, Perth, WA, Australia.,Institute of Clinical Trial and Methodology, University College London, London, UK.,Division of Surgery, University College London, London, UK
| | | | - Ben Clevenger
- Division of Surgery, University College London, London, UK.,Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Anna Butcher
- Division of Surgery, University College London, London, UK
| | - Sandy Abeysiri
- Institute of Clinical Trial and Methodology, University College London, London, UK.,Division of Surgery, University College London, London, UK
| | - Marisa Chau
- Institute of Clinical Trial and Methodology, University College London, London, UK.,Division of Surgery, University College London, London, UK
| | - Rebecca Swinson
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Collier
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Van Dyck
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Iain Macdougall
- Department of Renal Medicine, King's College Hospital, London, UK
| | - Gavin Murphy
- NIHR Leicester Biomedical Research Centre, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Andrew Bradbury
- University Department of Vascular Surgery (University of Birmingham), Solihull Hospital, Solihull, UK
| | - Andrew Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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9
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Richards T, Baikady RR, Clevenger B, Butcher A, Abeysiri S, Chau M, Macdougall IC, Murphy G, Swinson R, Collier T, Van Dyck L, Browne J, Bradbury A, Dodd M, Evans R, Brealey D, Anker SD, Klein A. Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial. Lancet 2020; 396:1353-1361. [PMID: 32896294 PMCID: PMC7581899 DOI: 10.1016/s0140-6736(20)31539-7] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Preoperative anaemia affects a high proportion of patients undergoing major elective surgery and is associated with poor outcomes. We aimed to test the hypothesis that intravenous iron given to anaemic patients before major open elective abdominal surgery would correct anaemia, reduce the need for blood transfusions, and improve patient outcomes. METHODS In a double-blind, parallel-group randomised trial, we recruited adult participants identified with anaemia at preoperative hospital visits before elective major open abdominal surgery at 46 UK tertiary care centres. Anaemia was defined as haemoglobin less than 130 g/L for men and 120 g/L for women. We randomly allocated participants (1:1) via a secure web-based service to receive intravenous iron or placebo 10-42 days before surgery. Intravenous iron was administered as a single 1000 mg dose of ferric carboxymaltose in 100 mL normal saline, and placebo was 100 mL normal saline, both given as an infusion over 15 min. Unblinded study personnel prepared and administered the study drug; participants and other clinical and research staff were blinded to treatment allocation. Coprimary endpoints were risk of the composite outcome of blood transfusion or death, and number of blood transfusions from randomisation to 30 days postoperatively. The primary analysis included all randomly assigned patients with data available for the primary endpoints; safety analysis included all randomly assigned patients according to the treatment received. This study is registered, ISRCTN67322816, and is closed to new participants. FINDINGS Of 487 participants randomly assigned to placebo (n=243) or intravenous iron (n=244) between Jan 6, 2014, and Sept 28, 2018, complete data for the primary endpoints were available for 474 (97%) individuals. Death or blood transfusion occurred in 67 (28%) of the 237 patients in the placebo group and 69 (29%) of the 237 patients in the intravenous iron group (risk ratio 1·03, 95% CI 0·78-1·37; p=0·84). There were 111 blood transfusions in the placebo group and 105 in the intravenous iron group (rate ratio 0·98, 95% CI 0·68-1·43; p=0·93). There were no significant differences between the two groups for any of the prespecified safety endpoints. INTERPRETATION Preoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10-42 days before elective major abdominal surgery. FUNDING UK National Institute of Health Research Health Technology Assessment Program.
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Affiliation(s)
- Toby Richards
- Division of Surgery, University of Western Australia, Fiona Stanley Hospital, Perth, WA, Australia; Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK.
| | | | - Ben Clevenger
- Department of Anaesthesia, Royal National Orthopaedic Hospital, London, UK
| | - Anna Butcher
- Division of Surgery, University College London, London, UK
| | - Sandy Abeysiri
- Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK
| | - Marisa Chau
- Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK
| | | | - Gavin Murphy
- NIHR Leicester Biomedical Research Centre, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rebecca Swinson
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Collier
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Van Dyck
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Andrew Bradbury
- University Department of Vascular Surgery, Birmingham University, Solihull Hospital, Solihull, UK
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Evans
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - David Brealey
- Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies, and German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andrew Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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10
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Nandhra S, Chau M, Klein AA, Yeates JA, Collier T, Evans C, Agarwal S, Richards T. Preoperative anaemia management in patients undergoing vascular surgery. Br J Surg 2020; 107:1558-1561. [PMID: 32996596 DOI: 10.1002/bjs.12041] [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] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/25/2020] [Accepted: 08/10/2020] [Indexed: 11/06/2022]
Abstract
CAVIAR is a multicentre prospective stepped observational study encompassing 160 patients undergoing vascular intervention. The aim was to identify whether it was feasible to establish a preoperative anaemia pathway and, if so, the efficacy of intravenous iron for treatment of preoperative anaemia. Large barriers prevented implementation of an intravenous iron pathway, with only ten patients receiving intravenous iron and a small increase in haemoglobin level (mean 5·7 (95 per cent c.i. 4·5 to 6·9) g/l). Preoperative anaemia was associated with a longer hospital stay and greater transfusion requirement. Anaemia common and dedicated pathway difficult to instigate.
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Affiliation(s)
- S Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Vascular Surgery, Newcastle University School of Population and Health Sciences, Newcastle upon Tyne, UK
| | - M Chau
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital Theatres Critical Care and Anaesthesia Services, Papworth Hospital, Cambridge, UK
| | - J A Yeates
- Department of Anaesthesia, St Vincent's Health Australia, Melbourne, Victoria, Australia
| | - T Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - C Evans
- Department of Anaesthetics, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - S Agarwal
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - T Richards
- Department of Vascular Surgery, University of Western Australia, Perth, Western Australia, Australia
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11
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Pellicori P, Ferreira JP, Mariottoni B, Brunner-La Rocca HP, Ahmed FZ, Verdonschot J, Collier T, Cuthbert JJ, Petutschnigg J, Mujaj B, Girerd N, González A, Clark AL, Cosmi F, Staessen JA, Heymans S, Latini R, Rossignol P, Zannad F, Cleland JGF. Effects of spironolactone on serum markers of fibrosis in people at high risk of developing heart failure: rationale, design and baseline characteristics of a proof-of-concept, randomised, precision-medicine, prevention trial. The Heart OMics in AGing (HOMAGE) trial. Eur J Heart Fail 2020; 22:1711-1723. [PMID: 31950604 DOI: 10.1002/ejhf.1716] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Asymptomatic patients with coronary artery disease (CAD), hypertension and/or type 2 diabetes mellitus (T2DM) are at greater risk of developing heart failure (HF). Fibrosis, leading to myocardial and vascular dysfunction, might be an important pathway of progression. The Heart OMics in AGing (HOMAGE) trial aims to investigate the effects of spironolactone on serum markers of collagen metabolism and on cardiovascular structure and function in people at risk of developing HF and potential interactions with a marker of fibrogenic activity, galectin-3. METHODS AND RESULTS The HOMAGE trial is a prospective, randomised, open-label, blinded endpoint (PROBE) study comparing spironolactone (up to 50 mg/day) and standard care over 9 months in people with clinical risk factors for developing HF, including hypertension, CAD and T2DM, and elevated plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP, 125 to 1000 ng/L) or B-type natriuretic peptide (BNP, 35 to 280 ng/L). Exclusion criteria included left ventricular ejection fraction < 45%, atrial fibrillation, severe renal dysfunction, or treatment with loop diuretics. The primary endpoint was the interaction between change in serum concentrations of procollagen type III N-terminal propeptide (PIIINP) and treatment with spironolactone according to median plasma concentrations of galectin-3 at baseline. For the 527 participants enrolled, median (interquartile range) age was 73 (69-79) years, 135 (26%) were women, 412 (78%) had hypertension, 377 (72%) CAD, and 212 (40%) T2DM. At baseline, medians (interquartile ranges) were for left ventricular ejection fraction 63 (58-67) %, for left atrial volume index 31 (26-37) mL/m2 , for plasma NT-proBNP 214 (137-356) ng/L, for serum PIIINP 3.9 (3.1-5.0) ng/mL, and for galectin-3 16.1 (13.5-19.7) ng/mL. CONCLUSIONS The HOMAGE trial will provide insights on the effect of spironolactone on pathways that might drive progression to HF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02556450.
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Affiliation(s)
- Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | | | | | - Fozia Z Ahmed
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Job Verdonschot
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Joe J Cuthbert
- Department of Academic Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Johannes Petutschnigg
- Department of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Blerim Mujaj
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain.,CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Franco Cosmi
- Department of Cardiology, Cortona Hospital, Arezzo, Italy
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Stephane Heymans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium.,The Netherlands Heart Institute, Utrecht, The Netherlands
| | - Roberto Latini
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
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12
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Smith TO, Collier T, Sheehan KJ, Sherrington C. The uptake of the hip fracture core outcome set: analysis of 20 years of hip fracture trials. Age Ageing 2019; 48:595-598. [PMID: 30843578 DOI: 10.1093/ageing/afz018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/28/2018] [Accepted: 02/11/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND clinical trials test the effectiveness or efficacy of treatments. It is important that researchers evaluate interventions with the most meaningful outcome measures. The 2014 hip fracture core outcome set recommended that mortality, mobility, pain, activities of daily living and health-related quality of life (HRQOL) should be assessed in all trials of patient with hip fracture. The purpose of this analysis was to determine the uptake of these recommendation. METHODS all trials registered from 1997 to 2018 recruiting participants following hip fracture were identified from the ClinicalTrials.gov trials registry. The frequency of each core domain adopted annually were assessed. RESULTS 311 trials were identified and analysed. On analysing trial registries for years which presented a minimum of 10 registrations, full core outcome set adoption ranged from 0% (2017; 2018) to 24% (2009). Mortality and mobility were the most consistently reported domains (mortality: 27% (2017) to 56% (2011); mobility: 36% (2015) to 60% (2004)). In contrast, pain and HRQOL were least reported (pain: 14% (2017) to 61% (2015); HRQOL: 10% (2010) to 11% (2008)). There was no clear change in core outcome domain set adoption following the publication of Hayward et al.'s (2014) core outcome set. CONCLUSIONS there has been limited adoption of the hip fracture core outcome set from its publication in 2014. Further consideration to improve implementation is required to improved uptake.
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Affiliation(s)
- T O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - T Collier
- Rheumatology Department, Queen Elizabeth Hospital, NHS Foundation Trust, Kings Lynn, Norfolk, UK
| | - K J Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - C Sherrington
- The University of Sydney School of Medicine, The University of Sydney, Australia
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13
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Gupta A, Mackay J, Whitehouse A, Godec T, Collier T, Pocock S, Poulter N, Sever P. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. Lancet 2018; 392:1127-1137. [PMID: 30158072 DOI: 10.1016/s0140-6736(18)31776-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [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] [Received: 07/13/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with hypertension, the long-term cardiovascular and all-cause mortality effects of different blood pressure-lowering regimens and lipid-lowering treatment are not well documented, particularly in clinical trial settings. The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy Study reports mortality outcomes after 16 years of follow-up of the UK participants in the original ASCOT trial. METHODS ASCOT was a multicentre randomised trial with a 2 × 2 factorial design. UK-based patients with hypertension were followed up for all-cause and cardiovascular mortality for a median of 15·7 years (IQR 9·7-16·4 years). At baseline, all patients enrolled into the blood pressure-lowering arm (BPLA) of ASCOT were randomly assigned to receive either amlodipine-based or atenolol-based blood pressure-lowering treatment. Of these patients, those who had total cholesterol of 6·5 mmol/L or lower and no previous lipid-lowering treatment underwent further randomisation to receive either atorvastatin or placebo as part of the lipid-lowering arm (LLA) of ASCOT. The remaining patients formed the non-LLA group. A team of two physicians independently adjudicated all causes of death. FINDINGS Of 8580 UK-based patients in ASCOT, 3282 (38·3%) died, including 1640 (38·4%) of 4275 assigned to atenolol-based treatment and 1642 (38·1%) of 4305 assigned to amlodipine-based treatment. 1768 of the 4605 patients in the LLA died, including 903 (39·5%) of 2288 assigned placebo and 865 (37·3%) of 2317 assigned atorvastatin. Of all deaths, 1210 (36·9%) were from cardiovascular-related causes. Among patients in the BPLA, there was no overall difference in all-cause mortality between treatments (adjusted hazard ratio [HR] 0·90, 95% CI 0·81-1·01, p=0·0776]), although significantly fewer deaths from stroke (adjusted HR 0·71, 0·53-0·97, p=0·0305) occurred in the amlodipine-based treatment group than in the atenolol-based treatment group. There was no interaction between treatment allocation in the BPLA and in the LLA. However, in the 3975 patients in the non-LLA group, there were fewer cardiovascular deaths (adjusted HR 0·79, 0·67-0·93, p=0·0046) among those assigned to amlodipine-based treatment compared with atenolol-based treatment (p=0·022 for the test for interaction between the two blood pressure treatments and allocation to LLA or not). In the LLA, significantly fewer cardiovascular deaths (HR 0·85, 0·72-0·99, p=0·0395) occurred among patients assigned to statin than among those assigned placebo. INTERPRETATION Our findings show the long-term beneficial effects on mortality of antihypertensive treatment with a calcium channel blocker-based treatment regimen and lipid-lowering with a statin: patients on amlodipine-based treatment had fewer stroke deaths and patients on atorvastatin had fewer cardiovascular deaths more than 10 years after trial closure. Overall, the ASCOT Legacy study supports the notion that interventions for blood pressure and cholesterol are associated with long-term benefits on cardiovascular outcomes. FUNDING Pfizer.
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Affiliation(s)
- Ajay Gupta
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Judith Mackay
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Whitehouse
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Thomas Godec
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Peter Sever
- National Heart and Lung Institute, Imperial College London, London, UK.
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14
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Zochios V, Collier T, Blaudszun G, Butchart A, Earwaker M, Jones N, Klein AA. The effect of high-flow nasal oxygen on hospital length of stay in cardiac surgical patients at high risk for respiratory complications: a randomised controlled trial. Anaesthesia 2018; 73:1478-1488. [PMID: 30019747 PMCID: PMC6282568 DOI: 10.1111/anae.14345] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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] [Accepted: 04/29/2018] [Indexed: 01/27/2023]
Abstract
There has been increased interest in the prophylactic and therapeutic use of high‐flow nasal oxygen in patients with, or at risk of, non‐hypercapnic respiratory failure. There are no randomised trials examining the efficacy of high‐flow nasal oxygen in high‐risk cardiac surgical patients. We sought to determine whether routine administration of high‐flow nasal oxygen, compared with standard oxygen therapy, leads to reduced hospital length of stay after cardiac surgery in patients with pre‐existing respiratory disease at high risk for postoperative pulmonary complications. Adult patients with pre‐existing respiratory disease undergoing elective cardiac surgery were randomly allocated to receive high‐flow nasal oxygen (n = 51) or standard oxygen therapy (n = 49). The primary outcome was hospital length of stay and all analyses were carried out on an intention‐to‐treat basis. Median (IQR [range]) hospital length of stay was 7 (6–9 [4–30]) days in the high‐flow nasal oxygen group and 9 (7–16 [4–120]) days in the standard oxygen group (p=0.012). Geometric mean hospital length of stay was 29% lower in the high‐flow nasal group (95%CI 11–44%, p = 0.004). High‐flow nasal oxygen was also associated with fewer intensive care unit re‐admissions (1/49 vs. 7/45; p = 0.026). When compared with standard care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. This is the first randomised controlled trial examining the effect of prophylactic high‐flow nasal oxygen use on patient‐centred outcomes in cardiac surgical patients at high risk for postoperative respiratory complications.
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Affiliation(s)
- V Zochios
- Department of Intensive Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, University of Birmingham, UK
| | - T Collier
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK
| | - G Blaudszun
- Department of Anaesthesia, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Genève, Switzerland
| | - A Butchart
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
| | - M Earwaker
- Research and Development Department, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
| | - N Jones
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK.,Department of Anaesthesia and Intensive Care, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
| | - A A Klein
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK.,Department of Anaesthesia and Intensive Care, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
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15
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Lees J, Michalopoulou PG, Lewis SW, Preston S, Bamford C, Collier T, Kalpakidou A, Wykes T, Emsley R, Pandina G, Kapur S, Drake RJ. Modafinil and cognitive enhancement in schizophrenia and healthy volunteers: the effects of test battery in a randomised controlled trial. Psychol Med 2017; 47:2358-2368. [PMID: 28464963 DOI: 10.1017/s0033291717000885] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cognitive deficits in schizophrenia have major functional impacts. Modafinil is a cognitive enhancer whose effect in healthy volunteers is well-described, but whose effects on the cognitive deficits of schizophrenia appear to be inconsistent. Two possible reasons for this are that cognitive test batteries vary in their sensitivity, or that the phase of illness may be important, with patients early in their illness responding better. METHODS A double-blind, randomised, placebo-controlled single-dose crossover study of modafinil 200 mg examined this with two cognitive batteries [MATRICS Consensus Cognitive Battery (MCCB) and Cambridge Neuropsychological Test Automated Battery (CANTAB)] in 46 participants with under 3 years' duration of DSM-IV schizophrenia, on stable antipsychotic medication. In parallel, the same design was used in 28 age-, sex-, and education-matched healthy volunteers. Uncorrected p values were calculated using mixed effects models. RESULTS In patients, modafinil significantly improved CANTAB Paired Associate Learning, non-significantly improved efficiency and significantly slowed performance of the CANTAB Stockings of Cambridge spatial planning task. There was no significant effect on any MCCB domain. In healthy volunteers, modafinil significantly increased CANTAB Rapid Visual Processing, Intra-Extra Dimensional Set Shifting and verbal recall accuracy, and MCCB social cognition performance. The only significant differences between groups were in MCCB visual learning. CONCLUSIONS As in earlier chronic schizophrenia studies, modafinil failed to produce changes in cognition in early psychosis as measured by MCCB. CANTAB proved more sensitive to the effects of modafinil in participants with early schizophrenia and in healthy volunteers. This confirms the importance of selecting the appropriate test battery in treatment studies of cognition in schizophrenia.
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Affiliation(s)
- J Lees
- Division of Psychology & Mental Health,School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - P G Michalopoulou
- Institute of Psychiatry,Psychology and Neuroscience,King's Health Partners,London,UK
| | - S W Lewis
- Division of Psychology & Mental Health,School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - S Preston
- Division of Psychology & Mental Health,School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - C Bamford
- Division of Psychology & Mental Health,School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - T Collier
- Institute of Psychiatry,Psychology and Neuroscience,King's Health Partners,London,UK
| | - A Kalpakidou
- Institute of Psychiatry,Psychology and Neuroscience,King's Health Partners,London,UK
| | - T Wykes
- Institute of Psychiatry,Psychology and Neuroscience,King's Health Partners,London,UK
| | - R Emsley
- Division of Population Health,Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - G Pandina
- Janssen Research & Development, LLC,New Brunswick,New Jersey,USA
| | - S Kapur
- Institute of Psychiatry,Psychology and Neuroscience,King's Health Partners,London,UK
| | - R J Drake
- Division of Psychology & Mental Health,School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
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16
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Klein A, Collier T, Yeates J, Miles L, Fletcher S, Evans C, Richards T. The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery. Br J Anaesth 2017; 119:394-401. [DOI: 10.1093/bja/aex205] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 01/09/2023] Open
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17
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Gupta A, Thompson D, Whitehouse A, Collier T, Dahlof B, Poulter N, Collins R, Sever P. Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase. Lancet 2017; 389:2473-2481. [PMID: 28476288 DOI: 10.1016/s0140-6736(17)31075-9] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [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] [Received: 12/20/2016] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND In blinded randomised controlled trials, statin therapy has been associated with few adverse events (AEs). By contrast, in observational studies, larger increases in many different AEs have been reported than in blinded trials. METHODS In the Lipid-Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Trial, patients aged 40-79 years with hypertension, at least three other cardiovascular risk factors, and fasting total cholesterol concentrations of 6·5 mmol/L or lower, and who were not taking a statin or fibrate, had no history of myocardial infarction, and were not being treated for angina were randomly assigned to atorvastatin 10 mg daily or matching placebo in a randomised double-blind placebo-controlled phase. In a subsequent non-randomised non-blind extension phase (initiated because of early termination of the trial because efficacy of atorvastatin was shown), all patients were offered atorvastatin 10 mg daily open label. We classified AEs using the Medical Dictionary for Regulatory Activities. We blindly adjudicated all reports of four prespecified AEs of interest-muscle-related, erectile dysfunction, sleep disturbance, and cognitive impairment-and analysed all remaining AEs grouped by system organ class. Rates of AEs are given as percentages per annum. RESULTS The blinded randomised phase was done between February, 1998, and December, 2002; we included 101 80 patients in this analysis (5101 [50%] in the atorvastatin group and 5079 [50%] in the placebo group), with a median follow-up of 3·3 years (IQR 2·7-3·7). The non-blinded non-randomised phase was done between December, 2002, and June, 2005; we included 9899 patients in this analysis (6409 [65%] atorvastatin users and 3490 [35%] non-users), with a median follow-up of 2·3 years (2·2-2·4). During the blinded phase, muscle-related AEs (298 [2·03% per annum] vs 283 [2·00% per annum]; hazard ratio 1·03 [95% CI 0·88-1·21]; p=0·72) and erectile dysfunction (272 [1·86% per annum] vs 302 [2·14% per annum]; 0·88 [0·75-1·04]; p=0·13) were reported at a similar rate by participants randomly assigned to atorvastatin or placebo. The rate of reports of sleep disturbance was significantly lower among participants assigned atorvastatin than assigned placebo (149 [1·00% per annum] vs 210 [1·46% per annum]; 0·69 [0·56-0·85]; p=0·0005). Too few cases of cognitive impairment were reported for a statistically reliable analysis (31 [0·20% per annum] vs 32 [0·22% per annum]; 0·94 [0·57-1·54]; p=0·81). We observed no significant differences in the rates of all other reported AEs, with the exception of an excess of renal and urinary AEs among patients assigned atorvastatin (481 [1·87%] per annum vs 392 [1·51%] per annum; 1·23 [1·08-1·41]; p=0·002). By contrast, during the non-blinded non-randomised phase, muscle-related AEs were reported at a significantly higher rate by participants taking statins than by those who were not (161 [1·26% per annum] vs 124 [1·00% per annum]; 1·41 [1·10-1·79]; p=0·006). We noted no significant differences between statin users and non-users in the rates of other AEs, with the exception of musculoskeletal and connective tissue disorders (992 [8·69% per annum] vs 831 [7·45% per annum]; 1·17 [1·06-1·29]; p=0·001) and blood and lymphatic system disorders (114 [0·88% per annum] vs 80 [0·64% per annum]; 1·40 [1·04-1·88]; p=0·03), which were reported more commonly by statin users than by non-users. INTERPRETATION These analyses illustrate the so-called nocebo effect, with an excess rate of muscle-related AE reports only when patients and their doctors were aware that statin therapy was being used and not when its use was blinded. These results will help assure both physicians and patients that most AEs associated with statins are not causally related to use of the drug and should help counter the adverse effect on public health of exaggerated claims about statin-related side-effects. FUNDING Pfizer, Servier Research Group, and Leo Laboratories.
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Affiliation(s)
- Ajay Gupta
- National Heart and Lung Institute, Imperial College London, London, UK; Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, UK; William Harvey Research Institute, Queen Mary University of London, London, UK
| | - David Thompson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Whitehouse
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Bjorn Dahlof
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Neil Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Sever
- National Heart and Lung Institute, Imperial College London, London, UK.
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18
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Takeshita R, Sullivan L, Smith C, Collier T, Hall A, Brosnan T, Rowles T, Schwacke L. The Deepwater Horizon oil spill marine mammal injury assessment. ENDANGER SPECIES RES 2017. [DOI: 10.3354/esr00808] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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Mitchell J, Al-Sheklly B, Issa B, Collier T, Corfield D, Smith JA. S30 Sensations associated with experimentally evoked cough: a comparison of chronic cough patients with healthy controls. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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20
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Sever P, Gupta A, Thompson D, Whitehouse A, Collier T, Dahlof B, Poulter N. LBOS 01-04 THE TRUE INCIDENCE OF STATIN -RELATED ADVERSE EVENTS IN HYPERTENSIVE PATIENTS REVEALED BY COMPARISON OF BLINDED AND UN-BLINDED USE OF STATIN IN THE ANGLO-SCANDINAVIAN CARDIAC OUTCOMES TRIAL (ASCOT). J Hypertens 2016. [DOI: 10.1097/01.hjh.0000501498.29676.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Matsuzaki M, Sullivan R, Ekelund U, Krishna KVR, Kulkarni B, Collier T, Ben-Shlomo Y, Kinra S, Kuper H. Development and evaluation of the Andhra Pradesh Children and Parent Study Physical Activity Questionnaire (APCAPS-PAQ): a cross-sectional study. BMC Public Health 2016; 16:48. [PMID: 26787268 PMCID: PMC4717598 DOI: 10.1186/s12889-016-2706-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 01/09/2016] [Indexed: 12/05/2022] Open
Abstract
Background There is limited availability of context-specific physical activity questionnaires in low and middle income countries. The aim of this study was to develop and examine the validity of a new Indian physical activity questionnaire, the Andhra Pradesh Children and Parent Study Physical Activity Questionnaire (APCAPS-PAQ). Methods The current study was conducted with the cohort from the Hyderabad DXA Study (n = 2321), recruited in 2009-2010. Criterion validity (n = 245) was examined by comparing the APCAPS-PAQ to a combined heart rate and motion sensor worn for 8 days. Construct validity (n = 2321) was assessed with linear regression, comparing APCAPS-PAQ against BMI, percent body fat, and pulse rate. Results The APCAPS-PAQ criterion validity was variable depending on the PA intensity groups (ρ = 0.26, 0.07, 0.39; к = 0.14, 0.04, 0.16 for sedentary, light, moderate/vigorous physical activity (MVPA) respectively). Sedentary and light intensity activities from the questionnaire were underestimated when compared to the criterion data while MVPA in APCAPS-PAQ was overestimated. Higher time spent in sedentary activity in APCAPS-PAQ was associated with higher BMI and percent body fat, suggesting construct validity. Conclusions The APCAPS-PAQ validity is comparable to other physical activity questionnaires. This tool is able to assess sedentary behavior, moderate/vigorous activity and physical activity energy expenditure on a group level with reasonable validity. This new questionnaire may be used for ranking individuals according to their sedentary time and physical activity in southern India. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-2706-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mika Matsuzaki
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Ruth Sullivan
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Ulf Ekelund
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway.,MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | | | - Bharati Kulkarni
- National Institute of Nutrition, Hyderabad, India.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Tim Collier
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sanjay Kinra
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Hannah Kuper
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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22
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Richards T, Clevenger B, Keidan J, Collier T, Klein AA, Anker SD, Kelly JD. Erratum to: PREVENTT: preoperative intravenous iron to treat anaemia in major surgery: study protocol for a randomised controlled trial. Trials 2015. [PMID: 26204933 PMCID: PMC4513685 DOI: 10.1186/s13063-015-0869-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Affiliation(s)
- Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ben Clevenger
- Division of Surgery and Interventional Science, University College London, London, UK. .,Division of Surgery and Interventional Science, 4th Floor, University College London, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK.
| | - Jane Keidan
- Queen Elizabeth Hospital, King's Lynn NHS Trust, Suffolk, UK
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK
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23
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Ortmann E, Rubino A, Altemimi B, Collier T, Besser MW, Klein AA. Validation of viscoelastic coagulation tests during cardiopulmonary bypass. J Thromb Haemost 2015; 13:1207-16. [PMID: 25903995 DOI: 10.1111/jth.12988] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [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: 11/04/2014] [Accepted: 04/13/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND Viscoelastic point-of-care tests such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are increasingly used to guide hemostatic therapy after cardiac surgery. The aim of this study was to assess their clinical utility during cardiopulmonary bypass to predict postbypass coagulation status and to guide therapy. METHODS In this prospective study, TEG and ROTEM tests were performed in 52 adult patients undergoing elective cardiac surgery at two time points: near the end of cardiopulmonary bypass and after heparin reversal with protamine. The 95% confidence intervals of the mean difference were compared with a prespecified clinically relevant limit of ± 20% of the value after protamine. RESULTS Both viscoelastic fibrinogen assays were well within the prespecified clinically relevant limit (≥ 79% of patients). The laboratory Clauss fibrinogen was much lower during cardiopulmonary bypass than after protamine (mean difference 1.2 g L(-1) , 95% CI 1.03-1.4, which was outside a clinically acceptable difference. For intrinsically activated tests, clotting times (CT) were different and outside the prespecified limit on TEG (mean difference -1.2 min, 95% CI -1.8 to -0.6) but not on ROTEM (mean difference 2.3 sec, 95% CI -8.6 to 13.2), while clot strength was well within the clinical limit on both devices (≥ 94% of patients). For extrinsically activated tests, clot strength on both TEG and ROTEM was within the pre-specified limit in 98% of patients. CONCLUSIONS Results from TEG and ROTEM tests performed toward the end of cardiopulmonary bypass are similar to results after reversal of heparin. Amplitudes indicating clot strength were the most stable parameters across all tests, whereas CT showed more variability. In contrast, laboratory testing of fibrinogen using the Clauss assay was essentially invalid during cardiopulmonary bypass.
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Affiliation(s)
- E Ortmann
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - A Rubino
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - B Altemimi
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - T Collier
- London School of Hygiene and Tropical Medicine, London, UK
| | - M W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals Foundation Trust, Cambridge, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
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24
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Girerd N, Collier T, Pocock S, Krum H, McMurray JJ, Swedberg K, Van Veldhuisen DJ, Vincent J, Pitt B, Zannad F. Clinical benefits of eplerenone in patients with systolic heart failure and mild symptoms when initiated shortly after hospital discharge: analysis from the EMPHASIS-HF trial. Eur Heart J 2015; 36:2310-7. [PMID: 26093641 DOI: 10.1093/eurheartj/ehv273] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 05/27/2015] [Indexed: 12/25/2022] Open
Abstract
AIMS Cardiovascular hospitalization (CVH) in patients with heart failure (HF) is associated with a high post-discharge rate of early re-admission and CV death. Eplerenone might be effective in reducing the incidence of these adverse clinical outcomes during this period. METHODS AND RESULTS The EMPHASIS-HF trial compared eplerenone with placebo added to standard therapy in 2737 patients with New York Heart Association class II HF and left ventricular ejection fraction ≤35%. We conducted a post hoc analysis in the 2338 patients randomized within 180 days of a CVH. The interaction between the time from the qualifying CVH to randomization and the primary outcome of CV death or hospitalization for HF (HHF), as well as other secondary outcomes, was assessed in Cox survival models. Most of the qualifying CVHs were HHF (N = 1496, 64.0%), acute coronary syndromes (N = 390, 16.7%), and arrhythmias (N = 197, 7.2%). The median time of study drug initiation from qualifying CVH was 42 days. The relative rate reductions in CV death/HHF, HHF, and all-cause mortality were similar (P for interaction = 0.65, 0.44, and 0.40, respectively) whether the treatment was initiated <42 or 42+ days after qualifying CVH. Absolute rate reductions were -5.61 [-8.67, -2.55] events per 100 patient × years in the <42 days group and -3.58 [-6.37, -0.79] in the 42+ days group. The adverse effects of eplerenone were also unaffected by the time from the qualifying CVH. CONCLUSION Eplerenone is safe, improves survival, and may prevent re-admission when initiated soon after a hospitalization for HF or acute coronary syndromes in patients with systolic HF and mild symptoms.
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Affiliation(s)
- Nicolas Girerd
- INSERM, Centre D'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Henry Krum
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - John J McMurray
- The British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden National Heart and Lung Institute, Imperial College, London, UK
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Bertram Pitt
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Faiez Zannad
- INSERM, Centre D'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France
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25
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Richards T, Clevenger B, Keidan J, Collier T, Klein AA, Anker SD, Kelly JD. PREVENTT: preoperative intravenous iron to treat anaemia in major surgery: study protocol for a randomised controlled trial. Trials 2015; 16:254. [PMID: 26041028 PMCID: PMC4462008 DOI: 10.1186/s13063-015-0774-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 05/21/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Anaemia is common in patients undergoing major surgery. The current standard of care for patients with low haemoglobin in the peri-operative period is blood transfusion. The presence of preoperative anaemia is associated with an increased likelihood of the patient receiving peri-operative transfusion and worsened outcomes following surgery, more post-operative complications, delayed recovery and greater length of hospital stay. Intravenous iron, if applied in the preoperative setting, may correct anaemia by the time of surgery and reduce the need for blood transfusion and improve outcomes. METHODS/DESIGN PREVENTT is a phase III double-blind randomised controlled trial that will compare the use of intravenous ferric carboxymaltose (dose 1000 mg) with placebo 10-42 days before major open abdominal surgery in 500 patients with anaemia (haemoglobin < 120 g/L). The primary outcome measure will be the need for blood transfusion and secondary endpoints will include post-operative recovery, length of hospital stay, health care utilisation and cost analysis. TRIAL REGISTRATION ISRCTN67322816--registered 9 October 2012. ClinicalTrials.gov identifier: NCT01692418.
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Affiliation(s)
- Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Ben Clevenger
- Division of Surgery and Interventional Science, University College London, London, UK.
- Division of Surgery and Interventional Science, 4th Floor, UCL Medical School Building, 21 University Street, University College London, London, WC1E 6AU, UK.
| | - Jane Keidan
- Consultant Haematologist (retired), Queen Elizabeth Hospital, King's Lynn NHS Trust, Suffolk, UK.
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK.
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen (UMG), Göttingen, Germany.
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK.
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Ansari B, Hogan M, Collier T, Baddeley A, Scarci M, Coonar A, Bottrill F, Martinez G, Klein AA. The effect of prophylactic post-operative high flow nasal oxygen on patient recovery after lung resection surgery: a single blinded, randomised, controlled trial. J Cardiothorac Vasc Anesth 2015. [DOI: 10.1053/j.jvca.2015.05.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Krum H, Pitt B, McMurray J, Swedberg K, van Veldhuisen D, Pocock S, Collier T, Vincent J, Turgonyi E, Zannad F. O116 Does aspirin interfere with the clinical benefits of the mineralocorticoid receptor antagonist eplerenone in systolic chronic heart failure?: Analysis of the EMPHASIS-HF study. Glob Heart 2014. [DOI: 10.1016/j.gheart.2014.03.1327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Girerd N, Collier T, Pocock S, Krum H, Mcmurray J, Swedberg K, Van Veldhuisen D, Vincent J, Pitt B, Zannad F. Clinical benefits of Eplerenone in patients with systolic NYHA II heart failure when initiated shortly after hospital discharge. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht309.p3304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sullivan R, Kinra S, Ekelund U, Bharathi AV, Vaz M, Kurpad A, Collier T, Reddy KS, Prabhakaran D, Ebrahim S, Kuper H. Evaluation of the Indian Migration Study Physical Activity Questionnaire (IMS-PAQ): a cross-sectional study. Int J Behav Nutr Phys Act 2012; 9:13. [PMID: 22321669 PMCID: PMC3296617 DOI: 10.1186/1479-5868-9-13] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 02/09/2012] [Indexed: 12/04/2022] Open
Abstract
Background Socio-cultural differences for country-specific activities are rarely addressed in physical activity questionnaires. We examined the reliability and validity of the Indian Migration Study Physical Activity Questionnaire (IMS-PAQ) in urban and rural groups in India. Methods A sub-sample of IMS participants (n = 479) was used to examine short term (≤1 month [n = 158]) and long term (> 1 month [n = 321]) IMS-PAQ reliability for levels of total, sedentary, light and moderate/vigorous activity (MVPA) intensity using intraclass correlation (ICC) and kappa coefficients (k). Criterion validity (n = 157) was examined by comparing the IMS-PAQ to a uniaxial accelerometer (ACC) worn ≥4 days, via Spearman's rank correlations (ρ) and k, using Bland-Altman plots to check for systematic bias. Construct validity (n = 7,000) was established using linear regression, comparing IMS-PAQ against theoretical constructs associated with physical activity (PA): BMI [kg/m2], percent body fat and pulse rate. Results IMS-PAQ reliability ranged from ICC 0.42-0.88 and k = 0.37-0.61 (≤1 month) and ICC 0.26 to 0.62; kappa 0.17 to 0.45 (> 1 month). Criterion validity was ρ = 0.18-0.48; k = 0.08-0.34. Light activity was underestimated and MVPA consistently and substantially overestimated for the IMS-PAQ vs. the accelerometer. Criterion validity was moderate for total activity and MVPA. Reliability and validity were comparable for urban and rural participants but lower in women than men. Increasing time spent in total activity or MVPA, and decreasing time in sedentary activity were associated with decreasing BMI, percent body fat and pulse rate, thereby demonstrating construct validity. Conclusion IMS-PAQ reliability and validity is similar to comparable self-reported instruments. It is an appropriate tool for ranking PA of individuals in India. Some refinements may be required for sedentary populations and women in India.
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Affiliation(s)
- Ruth Sullivan
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
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Tomkins S, Collier T, Oralov A, Saburova L, McKee M, Shkolnikov V, Kiryanov N, Leon DA. Hazardous alcohol consumption is a major factor in male premature mortality in a typical Russian city: prospective cohort study 2003-2009. PLoS One 2012; 7:e30274. [PMID: 22347371 PMCID: PMC3275563 DOI: 10.1371/journal.pone.0030274] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [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: 09/27/2011] [Accepted: 12/12/2011] [Indexed: 11/19/2022] Open
Abstract
Introduction Russia has experienced massive fluctuations in mortality at working ages over the past three decades. Routine data analyses suggest that these are largely driven by fluctuations in heavy alcohol drinking. However, individual-level evidence supporting alcohol having a major role in Russian mortality comes from only two case-control studies, which could be subject to serious biases due to their design. Methods and Findings A prospective study of mortality (2003–9) of 2000 men aged 25–54 years at recruitment was conducted in the city of Izhevsk, Russia. This cohort was free from key limitations inherent in the design of the two earlier case-control studies. Cox proportional hazards regression was used to estimate hazard ratios of all-cause mortality by alcohol drinking type as reported by a proxy informant. Hazardous drinkers were defined as those who either drank non-beverage alcohols or were reported to regularly have hangovers or other behaviours related to heavy drinking episodes. Over the follow-up period 113 men died. Compared to non-hazardous drinkers and abstainers, men who drank hazardously had appreciably higher mortality (HR = 3.4, 95% CI 2.2, 5.1) adjusted for age, smoking and education. The population attributable risk percent (PAR%) for hazardous drinking was 26% (95% CI 14,37). However, larger effects were seen in the first two years of follow-up, with a HR of 4.6 (2.5, 8.2) and a corresponding PAR% of 37% (17, 51). Interpretation This prospective cohort study strengthens the evidence that hazardous alcohol consumption has been a major determinant of mortality among working age men in a typical Russian city. As such the similar findings of the previous case-control studies cannot be explained as artefacts of limitations of their design. As Russia struggles to raise life expectancy, which even in 2009 was only 62 years among men, control of hazardous drinking must remain a top public health priority.
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Affiliation(s)
- Susannah Tomkins
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tim Collier
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Vladimir Shkolnikov
- Max Planck Institute for Demographic Research, Rostock, Germany and New Economic School, Moscow, Russia
| | | | - David A. Leon
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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Wang D, Ariti C, Collier T, Pocock S. The win ratio: a new approach to the analysis of composite endpoints in clinical trials based on clinical priorities. Trials 2011. [PMCID: PMC3287787 DOI: 10.1186/1745-6215-12-s1-a69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sullivan R, Kinra S, Ekelund U, Bharathi AV, Vaz M, Kurpad A, Collier T, Reddy KS, Prabhakaran D, Ben-Shlomo Y, Davey Smith G, Ebrahim S, Kuper H. Socio-demographic patterning of physical activity across migrant groups in India: results from the Indian Migration Study. PLoS One 2011; 6:e24898. [PMID: 22022366 PMCID: PMC3194815 DOI: 10.1371/journal.pone.0024898] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [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: 06/08/2011] [Accepted: 08/19/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the relationship between rural to urban migration and physical activity (PA) in India. METHODS 6,447 (42% women) participants comprising 2077 rural, 2,094 migrants and 2,276 urban were recruited. Total activity (MET hr/day), activity intensity (min/day), PA Level (PAL) television viewing and sleeping (min/day) were estimated and associations with migrant status examined, adjusting for the sib-pair design, age, site, occupation, education, and socio-economic position (SEP). RESULTS Total activity was highest in rural men whereas migrant and urban men had broadly similar activity levels (p<0.001). Women showed similar patterns, but slightly lower levels of total activity. Sedentary behaviour and television viewing were lower in rural residents and similar in migrant and urban groups. Sleep duration was highest in the rural group and lowest in urban non-migrants. Migrant men had considerably lower odds of being in the highest quartile of total activity than rural men, a finding that persisted after adjustment for age, SEP and education (OR 0.53, 95% CI 0.37, 0.74). For women, odds ratios attenuated and associations were removed after adjusting for age, SEP and education. CONCLUSION Our findings suggest that migrants have already acquired PA levels that closely resemble long-term urban residents. Effective public health interventions to increase PA are needed.
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Affiliation(s)
- Ruth Sullivan
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Sullivan R, Kinra S, Ekelund U, Bharathi AV, Collier T, Vaz M, Kurpad A, Reddy KS, Prabhakaran D, Kuper H, Ebrahim S. P2-295 Socio-demographic patterns of physical activity in India: a cross sectional study. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976k.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Robinson B, Zhang J, Thumma J, Gillespie B, Combe C, Fukuhara S, Harambat J, Morgenstern H, Port F, Pisoni R, Collier T, Steenkamp R, Tomson C, Caskey F, Ansell D, Roderick P, Nitsch D, Chanouzas D, Ng KP, Fallouh B, Baharani J, Righetti M, Ferrario G, Serbelloni P, Milani S, Lisi L, Tommasi A, Okuno S, Ishimura E, Yamakawa K, Tsuboniwa N, Norimine K, Kagitani S, Shoji S, Yamakawa T, Nishizawa Y, Inaba M, de Jager DJ, Halbesma N, Krediet RT, Boeschoten EW, le Cessie S, Dekker FW, Grootendorst DC, Miranda AC, Bento D, Madeira J, Cruz J, Saglimbene VM, De berardis G, Pellegrini F, Johnson DW, Craig JC, Hegbrant JBA, Strippoli GFM, Tzanno C, Nisihara F, Stein G, Clesco P, Uezima C, Martins JP, Esposito P, Di Benedetto A, Tinelli C, De Silvestri A, Marcelli D, Dal Canton A, Capurro F, De Mauri A, David P, Navino C, Chiarinotti D, De Leo M, De Leo M, Sato Y, Sato M, Johtoku Y, Appunu K, Baharani J, Kara B, Severova- Andreevska G, Trajceska L, Gelev S, Amitov V, Sikole A, Lomidze M, Rtskhiladze I, Metreveli D, Bartel J, Abramishvili N, Zangurashvili L, Barnova M, Buachidze K, Jashiashvili N, Kankia N, Khitarishvili T, Dzagania T, Tschokhonelidze I, Sarishvili N, Shamanadze A, Amet S, Launay-Vacher V, Stengel B, Castot A, Frances C, Gauvrit JY, Grenier N, Reinhardt G, Clement O, Kreft-Jais C, Janus N, Choukroun G, Laville M, Deray G, Szlanka B, Borbas B, Joseph J, Somers F, Vanga SR, Alscher MD, Rutherford P, De Mauri A, Conte M, Capurro F, David P, De Maria M, Navino C, De Leo M, De Mauri A, Conte M, Capurro F, David P, Chiarinotti D, Navino C, De Leo M, Kan WC, Chien CC, Wang HY, Hwang JC, Wang CJ, Castledine C, Gilg J, Rogers C, Ben-Shlomo Y, Yoav C, Dattolo P, Amidone M, Antognoli G, Michelassi S, Sisca S, Pizzarelli F, Kimber A, Tomson C, Maggs C, Steenkamp R, Smith H, Madziarska K, Weyde W, Kopec W, Penar J, Krajewska M, Klak R, Zukowska Szczechowska E, Gosek K, Golebiowski T, Strempska B, Kusztal M, Klinger M, Ito M, Masakane I, Ito S, Nagasawa J, Liao SC, Lee IN, Cheng CT, Halle MP, Hertig A, Kengue AP, Ashuntantang G, Rondeau E, Ridel C, Selim G, Stojceva-Taneva O, Tozija L, Gelev S, Stojcev N, Dzekova P, Trajcevska L, Severova G, Pavleska S, Sikole A, Paunovic K, Dimitrijevic Z, Paunovic G, Ljubenovic S, Djordjevic V, Stojanovic M, Mitsopoulos E, Tsiatsiou M, Ginikopoulou E, Minasidis I, Kousoula V, Tsikeloudi M, Manou E, Tsakiris D, Ortalda V, Yabarek T, Aslam N, Tomei P, Messa M, Lupo A, Ito S, Masakane I, Kudo K, Ito M, Nagasawa J, Osthus TBH, Amro A, Preljevic V, Leivestad T, Dammen T, Os I, Panocchia N, Di Stasio E, Liberatori M, Tazza L, Bossola M, Wilson R, Smyth M, Copley JB, Hanafusa N, Yamagata K, Nishi H, Nishi S, Iseki K, Tsubakihara Y, Fusaro M, Tripepi G, Crepaldi G, Maggi S, D'Angelo A, Naso A, Plebani M, Vajente N, Giannini S, Calo L, Miozzo D, Cristofaro R, Gallieni M, Hung PH, Shen CH, Hsiao CY, Chiang PC, Hung KY. Epidemiology & outcome in CKD 5D (2). Clin Kidney J 2011. [DOI: 10.1093/ndtplus/4.s2.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sullivan R, Kuper H, Kinra S, Collier T, Ekelund U, Bharathi A, Vaz M, Kurpad A, Reddy KS, Prabhakaran D, Ebrahim S. Estimating The Reliability And Validity Of The IMS-PAQ For Assessing Physical Activity In India. Med Sci Sports Exerc 2011. [DOI: 10.1249/01.mss.0000401677.93812.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jennings C, Turner E, Mead A, Jones J, Collier T. P187 Poster EUROACTION: Do couples attending a hospital based multidisciplinary cardiovascular prevention and rehabilitation programme share the same lifestyle habits? Do they change together? Eur J Cardiovasc Nurs 2011. [DOI: 10.1016/s1474-51511160141-2] [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: 11/29/2022]
Affiliation(s)
| | - E. Turner
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - A. Mead
- Imperial College London, London, United Kingdom
| | - J. Jones
- Imperial College London, London, United Kingdom
| | - T. Collier
- Imperial College London, London, United Kingdom
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Madhavan L, Daley B, Boudreau R, Cole-Strauss A, Collier T. P2.189 Neural stem cell mediated neuroprotection in a rat model of Parkinson's disease: role of endogenous precursors and graft-expressed molecules. Parkinsonism Relat Disord 2009. [DOI: 10.1016/s1353-8020(09)70540-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fox KF, Porter A, Unsworth B, Collier T, Leech G, Mayet J. Report on a national echocardiography quality-control exercise. European Journal of Echocardiography 2008; 10:314-8. [DOI: 10.1093/ejechocard/jen248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wood DA, Kotseva K, Connolly S, Jennings C, Mead A, Jones J, Holden A, De Bacquer D, Collier T, De Backer G, Faergeman O. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008; 371:1999-2012. [PMID: 18555911 DOI: 10.1016/s0140-6736(08)60868-5] [Citation(s) in RCA: 465] [Impact Index Per Article: 29.1] [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: 12/21/2022]
Abstract
BACKGROUND Our aim was to investigate whether a nurse-coordinated multidisciplinary, family-based preventive cardiology programme could improve standards of preventive care in routine clinical practice. METHODS In a matched, cluster-randomised, controlled trial in eight European countries, six pairs of hospitals and six pairs of general practices were assigned to an intervention programme (INT) or usual care (UC) for patients with coronary heart disease or those at high risk of developing cardiovascular disease. The primary endpoints-measured at 1 year-were family-based lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescription of cardioprotective drugs. Analysis was by intention to treat. The trial is registered as ISRCTN 71715857. FINDINGS 1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC, respectively. In patients with coronary heart disease who smoked in the month before the event, 136 (58%) in the INT and 154 (47%) in the UC groups did not smoke 1 year afterwards (difference in change 10.4%, 95% CI -0.3 to 21.2, p=0.06). Reduced consumption of saturated fat (196 [55%] vs 168 [40%]; 17.3%, 6.4 to 28.2, p=0.009), and increased consumption of fruit and vegetables (680 [72%] vs 349 [35%]; 37.3%, 18.1 to 56.5, p=0.004), and oily fish (156 [17%] vs 81 [8%]; 8.9%, 0.3 to 17.5, p=0.04) at 1 year were greatest in the INT group. High-risk individuals and partners showed changes only for fruit and vegetables (p=0.005). Blood-pressure target of less than 140/90 mm Hg was attained by both coronary (615 [65%] vs 547 [55%]; 10.4%, 0.6 to 20.2, p=0.04) and high-risk (586 [58%] vs 407 [41%]; 16.9%, 2.0 to 31.8, p=0.03) patients in the INT groups. Achievement of total cholesterol of less than 5 mmol/L did not differ between groups, but in high-risk patients the difference in change from baseline to 1 year was 12.7% (2.4 to 23.0, p=0.02) in favour of INT. In the hospital group, prescriptions for statins were higher in the INT group (810 [86%] vs 794 [80%]; 6.0%, -0.5 to 11.5, p=0.04). In general practices in the intervention groups, angiotensin-converting enzyme inhibitors (297 [29%] INT vs 196 [20%] UC; 8.5%, 1.8 to 15.2, p=0.02) and statins (381 [37%] INT vs 232 [22%] UC; 14.6%, 2.5 to 26.7, p=0.03) were more frequently prescribed. INTERPRETATION To achieve the potential for cardiovascular prevention, we need local preventive cardiology programmes adapted to individual countries, which are accessible by all hospitals and general practices caring for coronary and high-risk patients.
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Affiliation(s)
- D A Wood
- Department of Cardiovascular Medicine, National Heart and Lung Institute at Charing Cross Campus, Imperial College, London, UK.
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Meada A, Jones J, Jennings C, Holden A, Connolly S, Kotseva K, Collier T, Bacquer DD, Backer GD, Wooda D. 1351 Changes in lifestyle habits and cardiovascular risk factors over one-year in a family based preventive cardiology programme in hospital and general practice: Results from EUROACTION. Eur J Cardiovasc Nurs 2008. [DOI: 10.1016/j.ejcnurse.2008.01.051] [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: 11/29/2022]
Affiliation(s)
- A. Meada
- Department of Cardiovascular Medicine, Imperial College, London, UK
| | - J. Jones
- Department of Cardiovascular Medicine, Imperial College, London, UK
- School of Health Sciences and Social Care, Brunel University, London, UK
| | - C. Jennings
- Department of Cardiovascular Medicine, Imperial College, London, UK
| | - A. Holden
- Department of Cardiovascular Medicine, Imperial College, London, UK
| | - S. Connolly
- Department of Cardiovascular Medicine, Imperial College, London, UK
| | - K. Kotseva
- Department of Cardiovascular Medicine, Imperial College, London, UK
| | - T. Collier
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - D. De Bacquer
- Department of Public Health, University of Ghent, Belgium
| | - G. De Backer
- Department of Public Health, University of Ghent, Belgium
| | - D. Wooda
- Department of Cardiovascular Medicine, Imperial College, London, UK
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Connolly SB, Collier T, Khugputh R, Tataree D, Kyereme K, Merritt S, Struthers AD, Fox KF. Brain natriuretic peptide testing for angina in a rapid-access chest pain clinic. QJM 2007; 100:779-83. [PMID: 17965439 DOI: 10.1093/qjmed/hcm098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients complaining of chest pain are frequently referred to secondary care, although the majority have pain of non-cardiac origin. AIM To investigate whether B-type natriuretic peptide (BNP) levels are predictive of a diagnosis of non-cardiac pain. DESIGN Cross-sectional study. METHODS Consecutive patients (n = 296) presenting to a rapid-access chest pain clinic (RACPC) received the usual clinical assessment plus near-patient BNP testing, with the assessor blinded to the result. After clinical assessment (including exercise stress testing if clinically indicated), pain was diagnosed likely/definitely cardiac or non-cardiac. RESULTS Median BNP was higher in those diagnosed with likely/definite cardiac chest pain (26.5 vs. 8 pg/ml) (p < 0.0001, Wilcoxon rank sum test). The odds ratio for cardiac pain in those with BNP <20 pg/ml was 0.25 (95%CI 0.14-0.47) (p < 0.0005); adjusting for age and sex reduced this to 0.41 (95%CI 0.20-0.83) (p = 0.01). The area under the curve (AUC) for the model including BNP, age and sex was 0.70. With BNP as a continuous variable, the AUC for the same model was 0.72. DISCUSSION In typical patients presenting to a RACPC, those with a BNP < or =20 pg/ml were significantly less likely to be diagnosed with cardiac pain. Near-patient BNP testing may have a role as a 'rule out test' for angina in patients presenting to a RACPC.
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Affiliation(s)
- S B Connolly
- Cardiovascular Medicine, Charing Cross Hospital, Fulham Palace Road, London.
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Kotseva K, Connolly S, Jennings C, Mead A, Jones J, Holden A, Collier T, De Bacquer D, De Backer G, Wood D. EUROACTION: An ESC project in preventive cardiology programme in coronary and high risk patients and their partners. Atherosclerosis 2007. [DOI: 10.1016/j.atherosclerosis.2007.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sokolov K, Aaron J, Kumar S, Mack V, Collier T, Coghlan L, Gillenwater A, Adler Storthz K, Follen M, Richards Kortum R. Molecular imaging of carcinogenesis with immuno-targeted nanoparticles. Conf Proc IEEE Eng Med Biol Soc 2007; 2004:5292-5. [PMID: 17271535 DOI: 10.1109/iembs.2004.1404478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Molecular characterization of cancer could have important clinical benefits such as earlier cancer detection based on molecular characterization, the ability to predict the risk of cancer progression, real time margin detection, the ability to rationally select molecular therapy and to monitor response to the therapy. We present a new class of molecular specific contrast agents for optical imaging of carcinogenesis in vivo - gold nanoparticles conjugated with monoclonal antibodies specific for cancer biomarkers.
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Affiliation(s)
- K Sokolov
- Department of Imaging Physics, Texas University, Houston, TX, USA
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Fox KF, Collier T, Wood DA, Serhan J, Sutcliffe S, Akhras F, Langford E. Contemporary mortality due to acute myocardial infarction, unstable angina and exertional angina in a population in South East London. QJM 2006; 99:437-43. [PMID: 16793846 DOI: 10.1093/qjmed/hcl064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Data on the contemporary mortality of coronary heart disease (CHD) are surprisingly sparse. AIM To describe the contemporary mortality of all manifestations of CHD. DESIGN Prospective follow-up of patients with a first presentation of CHD in a defined population. METHODS We studied 537 patients with a first presentation of acute myocardial infarction, unstable angina or new exertional angina in Bromley Health Authority, London (population 295,000). Patients were prospectively monitored for cardiac and non-cardiac mortality for a median of 6 years. RESULTS During a median 6 years follow-up, there were 88 (16%) deaths. Survival free from cardiac death was not significantly different between unstable angina (92%) and new exertional angina (94%), but was lower for acute myocardial infarction (84%). DISCUSSION Mortality from CHD appears to be falling. However, efforts to prevent myocardial infarction should continue to be a priority, because on-going early mortality remains high. New exertional angina should be diagnosed and managed promptly, as its mortality is similar to that of unstable angina.
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Affiliation(s)
- K F Fox
- Department of Cardiovascular Medicine, Imperial College London, London W6 8RF, UK.
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van Goor A, Wood D, Neubeck L, Collier T, Fox K, Lefroy D. 1445 The Patient's and Partner's Care Needs and Experience of Living with an Implantable Cardioverter Defibrillator—a Questionnaire Survey. Eur J Cardiovasc Nurs 2005. [DOI: 10.1177/147451510500400136] [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: 11/17/2022]
Affiliation(s)
| | - David Wood
- Hammersmith Hospitals NHS Trust, Imperial College, London
| | - Lis Neubeck
- Hammersmith Hospitals NHS Trust, Imperial College, London
| | - Tim Collier
- Hammersmith Hospitals NHS Trust, Imperial College, London
| | - Kevin Fox
- Hammersmith Hospitals NHS Trust, Imperial College, London
| | - David Lefroy
- Hammersmith Hospitals NHS Trust, Imperial College, London
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Gale EAM, Bingley PJ, Emmett CL, Collier T. European Nicotinamide Diabetes Intervention Trial (ENDIT): a randomised controlled trial of intervention before the onset of type 1 diabetes. Lancet 2004; 363:925-31. [PMID: 15043959 DOI: 10.1016/s0140-6736(04)15786-3] [Citation(s) in RCA: 296] [Impact Index Per Article: 14.8] [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: 01/05/2023]
Abstract
BACKGROUND Results of studies in animals and human beings suggest that type 1 diabetes is preventable. Nicotinamide prevents autoimmune diabetes in animal models, possibly through inhibition of the DNA repair enzyme poly-ADP-ribose polymerase and prevention of beta-cell NAD depletion. We aimed to assess whether high dose nicotinamide prevents or delays clinical onset of diabetes in people with a first-degree family history of type 1 diabetes. METHOD We did a randomised double-blind placebo-controlled trial of nicotinamide in 552 relatives with confirmed islet cell antibody (ICA) levels of 20 Juvenile Diabetes Federation (JDF) units or more, and a non-diabetic oral glucose tolerance test. Participants were recruited from 18 European countries, Canada, and the USA, and were randomly allocated oral modified release nicotinamide (1.2 g/m2) or placebo for 5 years. Random allocation was done with a pseudorandom number generator and we used size balanced blocks of four and stratified by age and national group. Primary outcome was development of diabetes, as defined by WHO criteria. Analysis was done on an intention-to-treat basis. FINDINGS There was no difference in the development of diabetes between the treatment groups. Of 159 participants who developed diabetes in the course of the trial, 82 were taking nicotinamide and 77 were on placebo. The unadjusted hazard ratio for development of diabetes was 1.07 (95% CI 0.78-1.45; p=0.69), and the hazard ratio adjusted for age-at-entry, baseline glucose tolerance, and number of islet autoantibodies detected was 1.01 (0.73-1.38; p=0.97). Of 168 (30.4%) participants who withdrew from the trial, 83 were on placebo. The number of serious adverse events did not differ between treatment groups. Nicotinamide treatment did not affect growth in children or first-phase insulin secretion. INTERPRETATION Large-scale controlled trials of interventions designed to prevent the onset of type 1 diabetes are feasible, but nicotinamide was ineffective at the dose we used.
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Bunn F, Collier T, Frost C, Ker K, Roberts I, Wentz R. Traffic calming for the prevention of road traffic injuries: systematic review and meta-analysis. Inj Prev 2003; 9:200-4. [PMID: 12966005 PMCID: PMC1730987 DOI: 10.1136/ip.9.3.200] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess whether area-wide traffic calming schemes can reduce road crash related deaths and injuries. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials, Medline, EMBASE, Sociological Abstracts Science (and social science) citation index, National Technical Information service, Psychlit, Transport Research Information Service, International Road Research Documentation, and Transdoc, and web sites of road safety organisation were searched; experts were contacted, conference proceedings were handsearched, and relevant reference lists were checked. INCLUSION CRITERIA Randomised controlled trials, and controlled before/after studies of area-wide traffic calming schemes designed to discourage and slow down through traffic on residential roads. METHODS Data were collected on road user deaths, injuries, and traffic crashes. For each study rate ratios were calculated, the ratio of event rates before and after intervention in the traffic calmed area divided by the corresponding ratio of event rates in the control area, which were pooled to give an overall estimate using a random effects model. FINDINGS Sixteen controlled before/after studies met our inclusion criteria. Eight studies reported the number of road user deaths: pooled rate ratio 0.63 (95% confidence interval (CI) 0.14 to 2.59). Sixteen studies reported the number of injuries (fatal and non-fatal): pooled rate ratio 0.89 (95% CI 0.80 to 1.00). All studies were in high income countries. CONCLUSION Area-wide traffic calming in towns and cities has the potential to reduce road traffic injuries. However, further rigorous evaluations of this intervention are needed, especially in low and middle income countries.
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Affiliation(s)
- F Bunn
- University of Hertfordshire, Centre for Research in Primary and Community Care, Hatfield, Herts, UK.
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Abstract
BACKGROUND Worldwide, each year over a million people are killed and some ten million people are permanently disabled in road traffic crashes. Post-licence driver education is used by many as a strategy to reduce traffic crashes. However, the effectiveness of post-licence driver education has yet to be ascertained. OBJECTIVES To quantify the effectiveness of post-licence driver education in reducing road traffic crashes. SEARCH STRATEGY We searched the following electronic databases: the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, TRANSPORT (NTIS, TRIS, TRANSDOC, IRRD), Road Res (ARRB), ATRI, National Research Register, PsycInfo, ERIC, SPECTR, Zetoc, SIGLE, Science (and Social Science) Citation Index. We searched the Internet, checked reference lists of relevant papers and contacted appropriate organisations. The search was not restricted by language or publication status. SELECTION CRITERIA Randomised controlled trials comparing post-licence driver education versus no education, or one form of post-licence driver education versus another. DATA COLLECTION AND ANALYSIS Two reviewers independently screened search results, extracted data and assessed methodological trial quality. MAIN RESULTS We found 24 trials of driver education, 23 conducted in the USA and one in Sweden. Twenty trials studied remedial driver education. The methodological quality of the trials was poor and three reported data unsuitable for meta-analysis. Nineteen trials reported traffic offences: pooled relative risk (RR) = 0.96, 95% confidence interval (95% CI) = 0.94, 0.98); trial heterogeneity was significant (p=<0.00001). Fifteen trials reported traffic crashes: pooled RR = 0.98 (95% CI 0.96, 1.01), trial heterogeneity was not significant (p=0.75). Four trials reported injury crashes: pooled RR = 1.12 (95% CI 0.88, 1.41), trial heterogeneity was significant (p=<0.00001). No one form of education (correspondence, group or individual) was found to be substantially more effective than another, nor was a significant difference found between advanced driver education and remedial driver education. Funnel plots indicated the presence of publication bias affecting the traffic offence and crash outcomes. REVIEWER'S CONCLUSIONS This systematic review provides no evidence that post-licence driver education is effective in preventing road traffic injuries or crashes. Although the results are compatible with a small reduction in the occurrence of traffic offences, this may be due to selection biases or bias in the included trials. Because of the large number of participants included in the meta-analysis (close to 300,000 for some outcomes) we can exclude, with reasonable precision, the possibility of even modest benefits.
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Affiliation(s)
- K Ker
- Public Health Intervention Research Unit, London School of Hygiene and Tropical Medicine, 49-51 Bedford Square, London, UK, WC1B 3DP
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Abstract
BACKGROUND It is estimated that by 2020 road traffic crashes will have moved from ninth to third in the world disease burden ranking, as measured in disability adjusted life years, and second in developing countries. The identification of effective strategies for the prevention of traffic related injuries is of global health importance. Area-wide traffic calming schemes that discourage through traffic on residential roads is one such strategy. OBJECTIVES To evaluate the effectiveness of area-wide traffic calming in preventing traffic related crashes, injuries, and deaths. SEARCH STRATEGY We searched the following electronic databases: Cochrane Injuries Group's Specialised Register, Cochrane Controlled Trials Register, MEDLINE, EMBASE and TRANSPORT (NTIS, TRIS, TRANSDOC). We searched the web sites of road safety organisations, handsearched conference proceedings, checked reference lists of relevant papers and contacted experts in the area. The search was not restricted by language or publication status. SELECTION CRITERIA Randomised controlled trials, and controlled before-after studies of area-wide traffic calming schemes. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data on type of study, characteristics of intervention and control areas, and length of data collection periods. Before and after data were collected on the total number of road traffic crashes, all road user deaths and injuries, pedestrian-motor vehicle collisions and road user deaths. The statistical package STATA was used to calculate rate ratios for each study, which were then pooled to give an overall estimate using a random effects model. MAIN RESULTS We found no randomised controlled trials, but 16 controlled before-after trials met our inclusion criteria. Seven studies were done in Germany, six in the UK, two in Australia and one in the Netherlands. There were no studies in low or middle income countries. Eight trials reported the number of road traffic crashes resulting in deaths. The pooled rate ratio was 0.63 (0.14, 2.59 95% CI). Sixteen studies reported the number of road traffic crashes resulting in injuries (fatal and non fatal). The pooled rate ratio was 0.89 (0.80, 1.00 95% CI). Nine studies reported the total number of road traffic crashes. The pooled rate ratio was 0.95 (0.81, 1.11 95% CI). Thirteen trials reported the number of pedestrian-motor vehicle collisions. The pooled rate ratio was 1.00 (0.84, 1.18). There was significant heterogeneity for the total number of crashes and deaths and injuries. REVIEWER'S CONCLUSIONS The results from this review suggest that area-wide traffic calming in towns and cities may be a promising intervention for reducing the number of road traffic injuries, and deaths. However, further rigorous evaluations of this intervention are needed.
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Affiliation(s)
- F Bunn
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, College Lane, Hatfield, Hertfordshire, UK, AL10 9PN.
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