Nucleoside Reverse Transcriptase Inhibitor Exposure Is Associated with Lower Alzheimer's Disease Risk: A Retrospective Cohort Proof-of-Concept Study

Brain somatic gene recombination (SGR) and the endogenous reverse transcriptases (RTs) that produce it have been implicated in the etiology of Alzheimer's disease (AD), suggesting RT inhibitors as novel prophylactics or therapeutics. This retrospective, proof-of-concept study evaluated the incidence of AD in people with human immunodeficiency virus (HIV) with or without exposure to nucleoside RT inhibitors (NRTIs) using de-identified medical claims data. Eligible participants were aged ≥60 years, without pre-existing AD diagnoses, and pursued medical services in the United States from October 2015 to September 2016. Cohorts 1 (N = 46,218) and 2 (N = 32,923) had HIV. Cohort 1 had prescription claims for at least one NRTI within the exposure period; Cohort 2 did not. Cohort 3 (N = 150,819) had medical claims for the common cold without evidence of HIV or antiretroviral therapy. The cumulative incidence of new AD cases over the ensuing 2.75-year observation period was lowest in patients with NRTI exposure and highest in controls. Age- and sex-adjusted hazard ratios showed a significantly decreased risk for AD in Cohort 1 compared with Cohorts 2 (HR 0.88, p < 0.05) and 3 (HR 0.84, p < 0.05). Sub-grouping identified a decreased AD risk in patients with NRTI exposure but without protease inhibitor (PI) exposure. Prospective clinical trials and the development of next-generation agents targeting brain RTs are warranted.

COVID-19 Vaccination Reactions and Risk of Breakthrough Infections Among People With Diabetes: Cohort Study Derived From Community Reporters

BACKGROUND

This exploratory study compares self-reported COVID-19 vaccine side effects and breakthrough infections in people who described themselves as having diabetes with those who did not identify as having diabetes.

OBJECTIVE

The study uses person-reported data to evaluate differences in the perception of COVID-19 vaccine side effects between adults with diabetes and those who did not report having diabetes.

METHODS

This is a retrospective cohort study conducted using data provided online by adults aged 18 years and older residing in the United States. The participants who voluntarily self-enrolled between March 19, 2021, and July 16, 2022, in the IQVIA COVID-19 Active Research Experience project reported clinical and demographic information, COVID-19 vaccination, whether they had experienced any side effects, test-confirmed infections, and consented to linkage with prescription claims. No distinction was made for this study to differentiate prediabetes or type 1 and type 2 diabetes nor to verify reports of positive COVID-19 tests. Person-reported medication use was validated using pharmacy claims and a subset of the linked data was used for a sensitivity analysis of medication effects. Multivariate logistic regression was used to estimate the adjusted odds ratios of vaccine side effects or breakthrough infections by diabetic status, adjusting for age, gender, education, race, ethnicity (Hispanic or Latino), BMI, smoker, receipt of an influenza vaccine, vaccine manufacturer, and all medical conditions. Evaluations of diabetes medication-specific vaccine side effects are illustrated graphically to support the examination of the magnitude of side effect differences for various medications and combinations of medications used to manage diabetes.

RESULTS

People with diabetes (n=724) reported experiencing fewer side effects within 2 weeks of vaccination for COVID-19 than those without diabetes (n=6417; mean 2.7, SD 2.0 vs mean 3.1, SD 2.0). The adjusted risk of having a specific side effect or any side effect was lower among those with diabetes, with significant reductions in fatigue and headache but no differences in breakthrough infections over participants' maximum follow-up time. Diabetes medication use did not consistently affect the risk of specific side effects, either using self-reported medication use or using only diabetes medications that were confirmed by pharmacy health insurance claims for people who also reported having diabetes.

CONCLUSIONS

People with diabetes reported fewer vaccine side effects than participants not reporting having diabetes, with a similar risk of breakthrough infection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04368065; https://clinicaltrials.gov/study/NCT04368065.

Daily COVID-19 symptom assessment over 28 days - findings from a daily direct-to-patient registry of COVID-19 positive patients

In January 2021, 999 COVID-19 positive adults in the US enrolled in an online, direct-to-patient registry to describe daily symptom severity and progression over 28 days. The most commonly reported and persistent symptoms were fatigue, headache, decreased sense of taste, decreased sense of smell, and cough. Fast resolving symptoms included gastrointestinal symptoms (nausea, vomiting, diarrhea) and those related to fever and chills. While more than half (56%) of patients reported overall symptom improvement during the 28-day study period, 60% of patients were still reporting at least 1 COVID-19 symptom at the end of 28 days. Risk factors for experiencing symptoms for longer duration included at least one of the following: older age (> 60 years), higher BMI, lung disease, and receiving medication for hypertension. The study demonstrates the value of patient-reported data to provide important and timely insights to COVID-19 disease and symptom progression and the potential of using real-world data to inform clinical trial design and endpoints.

Cognitive and other neuropsychiatric symptoms in COVID-19: analysis of person-generated longitudinal health data from a community-based registry

OBJECTIVE

To describe cognitive symptoms in people not hospitalised at study enrolment for SARS-CoV-2 infection and associated demographics, medical history, other neuropsychiatric symptoms and SARS-CoV-2 vaccination.

DESIGN

Longitudinal observational study.

SETTING

Direct-to-participant registry with community-based recruitment via email and social media including Google, Facebook and Reddit, targeting adult US residents. Demographics, medical history, COVID-19-like symptoms, tests and vaccinations were collected through enrolment and follow-up surveys.

PARTICIPANTS

Participants who reported positive COVID-19 test results between 15 December 2020 and 13 December 2021. Those with cognitive symptoms were compared with those not reporting such symptoms.

MAIN OUTCOME MEASURE

Self-reported cognitive symptoms (defined as 'feeling disoriented or having trouble thinking' from listed options or related written-in symptoms) RESULTS: Of 3908 participants with a positive COVID-19 test result, 1014 (25.9%) reported cognitive symptoms at any time point during enrolment or follow-up, with approximately half reporting moderate/severe symptoms. Cognitive symptoms were associated with other neuropsychiatric symptoms, including dysgeusia, anosmia, trouble waking up, insomnia, headache, anxiety and depression. In multivariate analyses, female sex (OR, 95% CI): 1.7 (1.3 to 2.2), age (40-49 years (OR: 1.5 (1.2-1.9) compared with 18-29 years), history of autoimmune disease (OR: 1.5 (1.2-2.1)), lung disease (OR: 1.7 (1.3-2.2)) and depression (OR: 1.4 (1.1-1.7)) were associated with cognitive symptoms. Conversely, black race (OR: 0.6 (0.5-0.9)) and COVID-19 vaccination before infection (OR: 0.6 (0.4-0.7)) were associated with reduced occurrence of cognitive symptoms.

CONCLUSIONS

In this study, cognitive symptoms among COVID-19-positive participants were associated with female gender, age, autoimmune disorders, lung disease and depression. Vaccination and black race were associated with lower occurrence of cognitive symptoms. A constellation of neuropsychiatric and psychological symptoms occurred with cognitive symptoms. Our findings suggest COVID-19's full health and economic burden may be underestimated.

TRIAL REGISTRATION NUMBER

NCT04368065.

COVID-19 Vaccinations in Pregnancy: Comparative Evaluation of Acute Side Effects and Self-Reported Impact on Quality of Life between Pregnant and Nonpregnant Women in the United States

OBJECTIVE

The objective of this study was to describe the acute side effects experienced by pregnant women who received a coronavirus disease 2019 (COVID-19) vaccine in the United States and to compare their experience to nonpregnant women of similar age.

STUDY DESIGN

Adults who received a COVID-19 vaccine in the United States were invited via social media to enroll in an online, longitudinal, community-based registry ( www.helpstopCOVID19.com ). Participants self-reported pregnancy status, vaccination dates, manufacturer, acute side effects, impact on work and self-care, medical consultation, and hospitalization. This analysis was restricted to women aged 20 to 39 at the time of vaccination. Side effects reported by pregnant women were compared to those reported by nonpregnant women.

RESULTS

This analysis included 946 pregnant women, with 572 (60%) receiving at least one dose of Pfizer, 321 (34%) Moderna, and 53 (6%) J&J, and 1,178 nonpregnant women. Demographic and medical history were similar across manufacturers for both cohorts.Overall, pregnant women reported similar side effects as nonpregnant women, with the most common being injection site reactions (83 vs. 87%), fatigue (72 vs.78%), and headache (45 vs. 59%). Pregnant women reported fewer side effects (median: 3 vs. 4, respectively). In both cohorts, very few reported seeking medical care (<5%) or being hospitalized (<0.3%) after vaccination. Fewer pregnant women reported working less after vaccination than nonpregnant women (32 vs. 40%) or trouble with self-care (32 vs. 46%), respectively.

CONCLUSION

Pregnant women reported similar COVID-19 vaccine side effects as nonpregnant women, although fewer total side effects; pregnant women judged these side effects to have less impact on work and self-care. While these results do not address pregnancy outcomes or long-term effects, findings about acute side effects and impact offer reassurance for all three vaccines in terms of tolerability.

KEY POINTS

· COVID vaccines were well tolerated by pregnant women.. · Pregnant women reported fewer total side effects.. · Pregnant women reported less impact on work and self-care..

Evaluating real-world COVID-19 vaccine effectiveness using a test-negative case-control design

Aim: It is important to assess if clinical trial efficacy translates into real-world effectiveness for COVID-19 vaccines. Materials & methods: We conducted a modified test-negative design (TND) to evaluate the real-world effectiveness of three COVID-19 vaccines. We defined cases in two ways: self-reported COVID-19-positive tests, and self-reported positive tests with ≥1 moderate/severe COVID-19 symptom. Results: Any vaccination was associated with a 95% reduction in subsequently reporting a positive COVID-19 test, and a 71% reduction in reporting a positive test and ≥1 moderate/severe symptom. Conclusion: We observed high effectiveness across all three marketed vaccines, both for self-reported positive COVID-19 tests and moderate/severe COVID-19 symptoms. This innovative TND approach can be implemented in future COVID-19 vaccine and treatment real-world effectiveness studies. Clinicaltrials.gov identifier:NCT04368065.

Evaluating real-world COVID-19 vaccine effectiveness. #COVID19 #Vaccines #TND #PRO #patientreportedoutcomes

How frequent are acute reactions to COVID-19 vaccination and who is at risk?

Introduction

Our objective was to describe and compare self-reported side effects of COVID-19 vaccines in the USA.

Methods

A web-based registry enrolled volunteers who received a COVID-19 vaccine between March 19–July 15, 2021. We collected self-reported short-term side effects, medical consultation, hospitalization, and quality of life impact following completed vaccination regimens (Pfizer, Moderna, J&J).

Results

We recruited 6,966 volunteers who completed their full course of vaccination (median age 48 years, IQR 35.0–62.0; 83.6% female): Pfizer 3,486; Moderna 2,857; J&J 623. Few (3.1%) sought medical care for post-vaccination side effects. Hospitalization (n = 17; 0.3%) and severe allergic reactions (n = 39; 0.6%) also were rare. Those with autoimmune disease or lung disease were approximately twice as likely to seek medical care (adjusted odds ratio (aOR) 2.01, 95% CI:1.39; 2.92 and aOR 1.70, 95% CI: 1.12; .58 respectively). 92.4% of participants reported ≥ 1 side effect (median 3), with injection site reactions (78.9%), fatigue (70.3%), headache (49.0%) reported most frequently. More side effects were reported after the second dose of two-dose vaccines (medians: 1 vs. 2 for Pfizer and 1 vs. 3 for Moderna for first and second doses respectively) versus 3 for J&J's single-dose vaccine. For the employed, the median number of workdays missed was one. Diabetics and those vaccinated against influenza were substantially less likely to report 3 or more symptoms (aOR 0.68, 95% CI: 0.56;0.82] and aOR 0.82, 95% CI: 0.73;0.93, respectively).

Discussion

The total side effect burden was, not unexpectedly, greater with two-dose regimens but all three vaccines appear relatively safe. Very few subjects reported side effects serious enough to warrant medical care or reported post-vaccination hospitalization. While these findings do not address possible long-term effects, they do inform on their short-term safety and tolerability and will hopefully provide some reassurance and positively inform the benefit-risk and pharmacoeconomic assessment for all three vaccines.

See Clinicaltrials.gov NCT04368065.

Wooden hoof blocks: are we using the right wood?

AIMS

To investigate the association between the density of wooden hoof blocks and resistance to wear in pasture-based dairy herds, and to assess the density of commercially available wooden hoof blocks.

METHODS

Three types of wooden hoof blocks with different densities (low, medium and high) were attached to 36 lactating dairy cows with parity ≤2 and sound locomotion (score ≤2 on a scale of 1-4). The height of wooden blocks was measured in three different regions, front, abaxial and caudal on Days 7, 11, 14, 18, 21, 25 and 28 after application. Due to the loss of low-density wooden blocks, the data for these blocks were analysed for only two measurements on Days 7 and 11. The data for medium and high-density wooden blocks were analysed from Days 7-25. A linear mixed model with repeated measures was used to analyse the repeated observations. Height, density and surface area of commercially available hoof blocks (n = 19) were measured and compared to the blocks used in this study.

RESULTS

The magnitude of wear, in the front and the abaxial point of the blocks were greater in blocks made of low-density wood compared to those made of medium and high-density wood (p < 0.001). The amount of wear increased over time for all groups (p < 0.001). Wood density was negatively associated with wear and loss. Measurements of commercial wooden blocks revealed that the 13/19 (63%) had lower density and 12/19 (68%) less surface area than the wooden blocks with medium density used in this study.

CONCLUSION

In this study, the density of the wood was significantly associated with the longevity of hoof blocks when applied to hooves of pasture-based dairy cows.

CLINICAL RELEVANCE

The longevity of the wooden hoof blocks applied to treat lame cows plays a significant role in the healing of the claw horn lesions. The density of a wooden hoof block affects the rate of wear of the block, and this should be considered by manufacturers and those treating lame cows.

Comparison of ICD-9-CM to ICD-10-CM Crosswalks Derived by Physician and Clinical Coder vs. Automated Methods

PURPOSE

To evaluate whether automated methods are sufficient for deriving ICD-10-CM algorithms by comparing ICD-9-CM to ICD-10-CM crosswalks from general equivalence mappings (GEMs) with physician/clinical coder-derived crosswalks.

PATIENTS AND METHODS

Forward mapping was used to derive ICD-10-CM crosswalks for 10 conditions. As a sensitivity analysis, forward-backward mapping (FBM) was also conducted for three clinical conditions. The physician/coder independently developed crosswalks for the same conditions. Differences between the crosswalks were summarized using the Jaccard similarity coefficient (JSC).

RESULTS

Physician/coder crosswalks were typically far more inclusive than GEMs crosswalks. Crosswalks for peripheral artery disease were most dissimilar (JSC: 0.06), while crosswalks for mild cognitive impairment (JSC: 1) and congestive heart failure (0.85) were most similar. FBM added ICD-10-CM codes for all three conditions but did not consistently increase similarity between crosswalks.

CONCLUSION

The GEMs and physician/coder algorithms rarely aligned fully; human review is still required for ICD-9-CM to ICD-10-CM crosswalk development.

A comparison of the safety and effectiveness of dabigatran and warfarin in non-valvular atrial fibrillation patients in a large healthcare system

Dabigatran is approved for stroke risk reduction in patients with nonvalvular atrial fibrillation (NVAF). Data from diverse clinical practice settings will help establish whether the risk:benefit ratio seen in clinical trials is comparable with routine clinical care. This study aimed to compare the safety and effectiveness of dabigatran and warfarin in clinical practice. We undertook a propensity score-matched (PSM) cohort study (N=12,793 per group; mean age 74) comparing treatment with dabigatran or warfarin in the US Department of Defense claims database, October 2009 to July 2013. Treatment-naïve patients with first prescription claim for dabigatran (either FDA-approved dose) or warfarin between October 2010 and July 2012 (index) and a diagnosis of NVAF during the 12 months before index date were included. Primary outcomes were stroke and major bleeding. Secondary outcomes included ischaemic and haemorrhagic stroke, major gastrointestinal (GI), urogenital or other bleeding, myocardial infarction (MI) and death. Time-to-event was investigated using Kaplan-Meier survival analyses. Outcomes comparisons were made utilising Cox-proportional hazards models of PSM groups. Dabigatran users experienced fewer strokes (adjusted hazard ratio [95 % confidence intervals] 0.73 [0.55-0.97]), major intracranial (0.49 [0.30-0.79]), urogenital (0.36 [0.18-0.74]) and other (0.38 [0.22-0.66]) bleeding, MI (0.65 [0.45-0.95]) and deaths (0.64 [0.55-0.74]) than the warfarin group. Major bleeding (0.87 [0.74-1.03]) and major GI bleeding (1.13 [0.94-1.37]) was similar between groups and major lower GI bleeding events were more frequent (1.30 [1.04-1.62]) with dabigatran. In conclusion, compared with warfarin, dabigatran treatment was associated with a lower risk of stroke and most outcomes measured, but increased incidence of major lower GI bleeding.

A common data model to assess cardiovascular hospitalization and mortality in atrial fibrillation patients using administrative claims and medical records

Purpose

Atrial fibrillation/flutter (AF) is frequently associated with cardiovascular comorbidities. Observational health care databases are commonly used for research purposes in studies of quality of care, health economics, outcomes research, drug safety, and epidemiology. This retrospective cohort study applied a common data model to administrative claims data (Truven Health Analytics MarketScan^® claims databases [MS-Claims]) and electronic medical records data (Geisinger Health System’s MedMining electronic medical record database [MG-EMR]) to examine the risk of cardiovascular hospitalization and all-cause mortality in relation to clinical risk factors in recent-onset AF and to assess the consistency of analyses for each data source.

Methods

Cohorts of patients with newly diagnosed AF (n=105,262 [MS-Claims] and n=3,919 [MG-EMR]) and demographically similar patients without AF (n=105,262 [MS-Claims] and n=3,872 [MG-EMR]) were followed from the qualifying AF diagnosis until cardiovascular hospitalization, death, database disenrollment, or study completion. A common data model standardized the data in structure, format, content, and nomenclature to allow for systematic assessment and comparison of outcomes from two disparate data sets.

Results

In both databases, AF patients had greater overall baseline comorbidity and higher incidence rates of cardiovascular hospitalization (threefold higher) and all-cause mortality (46% higher) than non-AF patients. For AF patients, incidence rates of cardiovascular hospitalization and all-cause mortality were increased by the concomitant presence of coronary disease, chronic obstructive pulmonary disease, and stroke at baseline. Overall, the pattern of cardiovascular hospitalization in the MS-Claims database was similar to that in the MG-EMR database. Compared with the MS-Claims database, the use of cardiovascular medications and the capture of certain comorbidities among AF patients appeared to be higher in the MG-EMR data set.

Conclusion

Similar standardized analyses across EMR and Claims databases were consistent in the association of AF with acute morbidity and an increased risk of all-cause mortality. Areas of inconsistency were due to differences in underlying population demographics and cardiovascular risks and completeness of certain data fields.

Clinical characteristics and healthcare utilization of patients with multicentric Castleman disease

Multicentric Castleman disease (MCD) is a rare lymphoproliferative disease. Little is known about how patient clinical features and healthcare utilization varies by human immunodeficiency virus (HIV) status and disease subtype. Data of MCD patients identified between 2000 and 2009 were collected from medical records at two United States treatment centres. Clinical, demographic, and biochemical characteristics, drug therapies and medical utilization were descriptively reported by HIV status and cell histology, and statistically compared with the Fisher's Exact and Kruskal-Wallis tests. Patients (n = 59) had a pathologically and clinically confirmed MCD diagnosis: plasmacytic (42%), hyaline vascular (29%) and mixed (15%); 10% had HIV infection. In the first year after diagnosis, MCD patients on average saw a healthcare provider more than six times, were hospitalized at least once and underwent frequent radiological and laboratory testing. Rituximab was the most commonly used drug therapy, followed by corticosteroids and conventional chemotherapy. One- and 2-year survival was excellent in HIV-negative patients (100% and 97%, respectively) but inferior for HIV-positive cases (67% and 67%, respectively). Heterogeneous treatment decisions were observed in this MCD study; HIV status was the only distinguishing clinical criteria associated with pharmacotherapies. Additional research is necessary to guide treatment of this rare lymphoproliferative disorder.

Clinical outcomes of concomitant therapy of exenatide twice daily and basal insulin in patients with type 2 diabetes mellitus: a retrospective database analysis in the United States

OBJECTIVE

To examine the clinical effectiveness of concomitant therapy of exenatide twice daily and basal insulin in patients with type 2 diabetes mellitus in the United States.

METHODS

Data from adults with type 2 diabetes were selected from an electronic medical record database. Concomitant therapy was defined as a basal insulin prescription within 6 months before or after an exenatide prescription between May 2005 and April 2009. Upon initiation, patients were treated with both medications. Clinical effectiveness was measured as mean changes in hemoglobin A1c (primary outcome), body weight, body mass index, blood pressure, and lipid values from a 6-month baseline to mean-adjusted values in a 12-month follow-up period. These changes were assessed by a bootstrapping test.

RESULTS

There were 1752 patients (mean age, 57 years) who initiated concomitant therapy (75% added exenatide to basal insulin, 25% added basal insulin to exenatide). Patients achieved significant mean reductions in hemoglobin A1c (0.5%), body weight (1.8 kg), body mass index (0.6 kg/m2), diastolic blood pressure (0.5 mm Hg), and various lipid measures (all P<.05). Hemoglobin A1c reduction was consistent irrespective of the treatment order. However, body weight, body mass index, and blood pressure reductions were observed in only patients who added exenatide to basal insulin.

CONCLUSIONS

Overall, exenatide and basal insulin concomitant therapy was associated with significant reductions in hemoglobin A1c, body weight, body mass index, diastolic blood pressure, and lipids in a large, diverse patient population treated in ambulatory care settings in the United States. In the subgroup analysis, body weight, body mass index, and diastolic blood pressure reductions were observed in only patients who added exenatide to basal insulin.

Costs associated with febrile neutropenia in the US

BACKGROUND AND OBJECTIVE

Febrile neutropenia (FN) is a potentially life-threatening condition that may develop in cancer patients treated with myelosuppressive chemotherapy and result in considerable costs. This study was designed to estimate US healthcare utilization and costs in those experiencing FN by location of care, tumour type and mortality.

METHODS

Cancer patients who received chemotherapy between 2001 and 2006 were identified from the HealthCore Integrated Research Database®, a longitudinal claims database with enrolment, medical, prescription and mortality information covering 12 health plans and more than 20 million US patients. Patients who experienced FN were prospectively matched using propensity score methods within each tumour type of interest (non-Hodgkin's lymphoma, breast, lung, colorectal and ovarian cancer) to those not experiencing FN. Health resource utilization was compared per patient per month for unique prescriptions and visits (inpatient and outpatient) over the length of follow-up. Healthcare total paid costs adjusted to 2009 US dollars per patient per month were examined by FN group (FN vs non-FN, FN died vs FN survived), by source of care (physician office visit, outpatient services, hospitalization and prescriptions) and by tumour type. The number of unique FN-related encounters (inpatient and outpatient) and the number of patients experiencing at least one FN-related encounter were examined. The costs per encounter were tabulated. FN encounters differ from FN episodes in that a single FN episode may include multiple FN encounters (i.e. a patient is seen multiple times [encounters] for treatment of a single FN event [episode]).

RESULTS

A total of 5990 patients each were successfully matched between the FN and non-FN (control) groups. Health resource utilization was generally higher in those with FN than in controls. FN patients incurred greater costs (mean ± SD: $US9628 ± 12 517 per patient-month) than non-FN patients ($US8478 ± 12 978). Chemotherapy comprised the majority of costs for both FN (33.5%) and non-FN (40.6%) patients. The largest cost difference by categorical source of care was for hospitalization (p < 0.001). FN patients who died had the highest mean total costs compared with FN surviving patients ($US21 214 ± 25 596 per patient-month vs $US8227 ± 8850, respectively). Follow-up time for those surviving was, on average, 6.6 months longer. Hospitalization accounted for 53.1% of costs in those experiencing mortality with FN, while chemotherapy accounted for the majority of costs (37.1%) in surviving FN patients. A total of 6574 patients with at least one FN encounter experienced a total of 55 726 unique FN-related encounters, 90% of which were outpatient in nature. The majority of FN-related encounters (79%) occurred during the first chemotherapy course. The average costs for FN encounters were highest for inpatient encounters, $US22 086 ± 43 407, compared with $US985 ± 1677 for outpatient encounters.

CONCLUSIONS

The occurrence of FN in cancer patients receiving chemotherapy results in greater healthcare resource utilization and costs, with FN patients who die accounting for the greatest healthcare costs. Most FN patients experience at least one outpatient FN encounter, and the total cost of treatment for FN continues to be high.

Metabolic outcomes of matched patient populations initiating exenatide BID vs. insulin glargine in an ambulatory care setting

AIM

This observational study evaluated the clinical effectiveness of exenatide BID (exenatide) vs. insulin glargine (glargine) in patients with type 2 diabetes mellitus in ambulatory clinical practice.

METHODS

Retrospective analyses were conducted using an electronic medical record (EMR) database among adult patients with type 2 diabetes mellitus initiating exenatide or glargine between 1 November 2006 and 30 April 2009. The cohorts were propensity-score matched to control baseline demographics, clinical measures, health status and medication use. The changes from baseline to a 12-month follow-up period for A1C (primary outcome), weight, body mass index (BMI), blood pressure and lipid levels were compared between the matched cohorts using paired tests.

RESULTS

Propensity-score matching between the exenatide (n = 4494) and glargine (n = 5424) cohorts led to 2683 matched pairs with comparable characteristics, including age, gender and baseline clinical values. The exenatide cohort achieved a greater mean reduction in A1C (-0.6% vs. -0.4%, p < 0.01), weight (-2.6 kg vs. -0.2 kg, p < 0.01), BMI (-0.8 kg/m(2) vs. -0.04 kg/m(2) , p < 0.01) and systolic blood pressure (SBP) (-1.8 mmHg vs. -0.1 mmHg, p < 0.01) in the follow-up period. The changes in diastolic blood pressure and lipid levels were not significantly different between cohorts.

CONCLUSIONS

Compared to glargine, exenatide-treated patients experienced significant reductions in A1C, weight, BMI and SBP. Acknowledging the limitations of observational research, exenatide showed greater clinical effectiveness than glargine from a large EMR database in the ambulatory care setting.

Metabolic outcomes of elderly patient populations initiating exenatide BID versus insulin glargine in an ambulatory care setting

AIMS

The safety and efficacy of exenatide BID (exenatide) and insulin glargine (glargine) have been studied in clinical trials with few elderly patients. This study examined the clinical effectiveness of exenatide compared to glargine in patients 65 years and older with type 2 diabetes mellitus (T2DM).

METHODS

A retrospective analysis was conducted using the General Electric electronic medical record database. Patients aged 65 years and older with T2DM who initiated exenatide or glargine were identified between November 1, 2006 and April 30, 2009 with 12 months of pre- and post-index continuous eligibility. Propensity-score matching (1:1) was used to balance baseline differences between the cohorts. The effectiveness endpoints were changes in A1C (primary endpoint), weight, body mass index (BMI), and blood pressure (BP). Matched cohorts were compared using paired t tests and nonparametric tests as appropriate.

RESULTS

The matched exenatide and glargine patients (n = 804 each) were comparable in their baseline characteristics, including age (70 vs. 71 years), and male sex (44.9% vs. 45.2%). In the 12-month follow-up, exenatide patients experienced significantly greater mean reductions in A1C (-0.5 vs. -0.2%), weight (-2.8 vs. -0.2 kg), BMI (-1.0 vs. -0.1 kg/m(2)), and systolic BP (-2.2 vs. 1.0 mmHg) (all: P < 0.05). More exenatide-treated patients reached the A1C goal of <7% (53.9% vs. 43.0%, P < 0.01). Diastolic BP was similar between the cohorts.

LIMITATIONS

Unmeasured confounding bias may still exist and thus findings should be interpreted as associations instead of causations. Due to incomplete data, adverse events and medication use were not examined.

CONCLUSION

Exenatide was associated with significant improvement in A1C, weight, BMI and BP compared to glargine for management of T2DM in an elderly patient population treated in ambulatory care settings.

A systematic review of validated methods for identifying hypersensitivity reactions other than anaphylaxis (fever, rash, and lymphadenopathy), using administrative and claims data

PURPOSE

The Food and Drug Administration's Mini-Sentinel pilot program aims to conduct active surveillance to refine safety signals that emerge for marketed medical products. A key facet of this surveillance is to develop and understand the validity of algorithms for identifying health outcomes of interest from administrative and claims data. This article summarizes the process and findings of the algorithm review of hypersensitivity reactions.

METHODS

PubMed and Iowa Drug Information Service searches were conducted to identify citations applicable to the hypersensitivity reactions of health outcomes of interest. Level 1 abstract reviews and Level 2 full-text reviews were conducted to find articles using administrative and claims data to identify hypersensitivity reactions and including validation estimates of the coding algorithms.

RESULTS

We identified five studies that provided validated hypersensitivity-reaction algorithms. Algorithm positive predictive values (PPVs) for various definitions of hypersensitivity reactions ranged from 3% to 95%. PPVs were high (i.e. 90%-95%) when both exposures and diagnoses were very specific. PPV generally decreased when the definition of hypersensitivity was expanded, except in one study that used data mining methodology for algorithm development.

CONCLUSIONS

The ability of coding algorithms to identify hypersensitivity reactions varied, with decreasing performance occurring with expanded outcome definitions. This examination of hypersensitivity-reaction coding algorithms provides an example of surveillance bias resulting from outcome definitions that include mild cases. Data mining may provide tools for algorithm development for hypersensitivity and other health outcomes. Research needs to be conducted on designing validation studies to test hypersensitivity-reaction algorithms and estimating their predictive power, sensitivity, and specificity.

A systematic review of validated methods for identifying acute respiratory failure using administrative and claims data

PURPOSE

The Food and Drug Administration's (FDA) Mini-Sentinel pilot program initially aims to conduct active surveillance to refine safety signals that emerge for marketed medical products. A key facet of this surveillance is to develop and understand the validity of algorithms for identifying health outcomes of interest (HOIs) from administrative and claims data. This paper summarizes the process and findings of the algorithm review of acute respiratory failure (ARF).

METHODS

PubMed and Iowa Drug Information Service searches were conducted to identify citations applicable to the anaphylaxis HOI. Level 1 abstract reviews and Level 2 full-text reviews were conducted to find articles using administrative and claims data to identify ARF, including validation estimates of the coding algorithms.

RESULTS

Our search revealed a deficiency of literature focusing on ARF algorithms and validation estimates. Only two studies provided codes for ARF, each using related yet different ICD-9 codes (i.e., ICD-9 codes 518.8, "other diseases of lung," and 518.81, "acute respiratory failure"). Neither study provided validation estimates.

CONCLUSIONS

Research needs to be conducted on designing validation studies to test ARF algorithms and estimating their predictive power, sensitivity, and specificity.

Over-the-counter ibuprofen and risk of gastrointestinal bleeding complications: a systematic literature review

BACKGROUND

Exposure to over-the-counter (OTC) ibuprofen and other OTC non-steroidal anti-inflammatory drugs (NSAIDs) is substantial. Although the literature on gastrointestinal (GI) safety of NSAID therapy is extensive, the risk profiles of OTC and prescription dosing are seldom separated, and few studies provide risks specific to OTC ibuprofen.

OBJECTIVE

To conduct a literature review to evaluate the risk of GI bleeding events related to OTC ibuprofen use.

METHODS

Published clinical trials, observational studies, and meta-analyses of OTC ibuprofen use, defined as up to 1200 mg/day or stated as 'over the counter,' reporting endpoints of incidence rates and proportions of GI bleeding events (e.g., GI bleeding-related hospitalizations and deaths) were identified via MEDLINE through 2010. Data from these studies were summarized.

RESULTS

Twenty studies (nine observational, ten clinical trials, one meta-analysis) reporting incidence rates and proportions of a GI bleeding-related event associated with OTC or OTC-specific doses of ibuprofen were included. The frequency of a GI-related hospitalization was <0.2% for patients on OTC-comparable doses. Incidence rates among those using OTC-comparable doses ranged from 0 to 3.19 per 1000 patient-years. The incidence of a GI bleeding-related event increased with age and the use of concomitant medications, and there was a general, though not always statistically significant, ibuprofen dose-response relationship. The relative risk of any GI bleeding-related event ranged from 1.1 to 2.4 for users of OTC-specific doses of ibuprofen compared to non-users.

CONCLUSIONS

Studies reported low incidence of GI bleeding events with use of OTC ibuprofen. Few published studies that specifically investigated OTC ibuprofen use were identified. Varying methodologies and definitions of exposure and outcomes prevented direct comparison of many results. Only studies that used the methods herein described were identified. Further research evaluating the risk of GI bleeding events in patients taking OTC-specific ibuprofen use may be useful.

Trend analyses of insulin delivery systems in the United States

BACKGROUND

Despite potential advantages in insulin pen delivery systems (IPDSs), the percentage of patients using an IPDS is relatively low in the United States.

OBJECTIVE

Our aim was to investigate the trend of initiating IPDSs among patients with type 2 diabetes mellitus (T2DM) who newly initiated insulin therapy.

METHODS

A retrospective analysis was conducted using a U.S. database from January 1, 2004, to December 31, 2008. Patients with T2DM who initiated a new insulin type and delivery system were included. The Cochran-Armitage test was used to assess the significance of the trend of initiating an insulin delivery system, including vial/syringe, IPDS overall, reusable pen delivery systems (RPDSs), and prefilled pen delivery systems (PPDSs). Different types of insulin (e.g., basal analog, prandial analog) were examined separately.

RESULTS

Patients initiating an IPDS increased from 10.6% in 2004 to 48.5% in 2008 (p < .001), most notably in basal analog and prandial analog insulin therapies. Although the percentage of patients using a PPDS increased by 36.2 percentage points (from 9.2% in 2004 to 45.4% in 2008; p < .001), use of a RPDS increased only by 1.7 percentage points (from 1.4% in 2004 to 3.1% in 2008; p < .001).

CONCLUSION

There was an overall increase in the use of IPDSs in the United States among patients with T2DM who newly initiated insulin from July 1, 2004, to December 31, 2008. This increase was driven by the use of PPDSs for basal analog and prandial analog insulin therapies. Despite the increasing use of IPDS over time, approximately 50% of patients still initiated insulin using a vial/syringe in 2008.

Methods to identify and compare parenteral nutrition administered from hospital-compounded and premixed multichamber bags in a retrospective hospital claims database

PURPOSE

Use of parenteral nutrition (PN) is indicated for patients who are unable to meet their needs enterally. PN may be administered via custom-compounded mix or commercially available ready-to-use multichamber bags (MCB), but little is known about potential differences in clinical outcomes between these delivery systems. This study was undertaken to assess the feasibility of comparing custom-compounded and MCB PN in a large hospital claims database.

METHODS

Hospital claims data from the Premier Perspective Comparative Hospital Database (PCD) reported from 2005 through 2007 were analyzed. The authors searched the data for patients who received any PN products, including compounded PN and MCB PN. Coding algorithms for identifying patient characteristics, risk factors, and outcomes of interest were explored.

RESULTS

Using hospital billing claims, the authors identified patients in the database treated with premixed PN from multichamber bags ("MCB only," n = 4699) and patients treated with custom-compounded PN solution ("compounded PN," n = 64,315). Methods of identifying PN administration groups, patient characteristics and risk factors, outcomes of interest, and data limitations are described.

CONCLUSIONS

Exploratory analysis suggests that comparisons of PN administered via compounding and MCB are possible using the Premier data. The ability to control for many identifiable risk factors allows data to be presented for the use of PN and related outcomes in both a clinically sensible and relevant manner, albeit with some limitations.

Impact of bleeding-related complications and/or blood product transfusions on hospital costs in inpatient surgical patients

Background

Inadequate surgical hemostasis may lead to transfusion and/or other bleeding-related complications. This study examines the incidence and costs of bleeding-related complications and/or blood product transfusions occurring as a consequence of surgery in various inpatient surgical cohorts.

Methods

A retrospective analysis was conducted using Premier's Perspective™ hospital database. Patients who had an inpatient procedure within a specialty of interest (cardiac, vascular, non-cardiac thoracic, solid organ, general, reproductive organ, knee/hip replacement, or spinal surgery) during 2006-2007 were identified. For each specialty, the rate of bleeding-related complications (including bleeding event, intervention to control for bleeding, and blood product transfusions) was examined, and hospital costs and length of stay (LOS) were compared between surgeries with and without bleeding-related complications. Incremental costs and ratios of average total hospital costs for patients with bleeding-related complications vs. those without complications were estimated using ordinary least squares (OLS) regression, adjusting for demographics, hospital characteristics, and other baseline characteristics. Models using generalized estimating equations (GEE) were also used to measure the impact of bleeding-related complications on costs while accounting for the effects related to the clustering of patients receiving care from the same hospitals.

Results

A total of 103,829 cardiac, 216,199 vascular, 142,562 non-cardiac thoracic, 45,687 solid organ, 362,512 general, 384,132 reproductive organ, 246,815 knee/hip replacement, and 107,187 spinal surgeries were identified. Overall, the rate of bleeding-related complications was 29.9% and ranged from 7.5% to 47.4% for reproductive organ and cardiac, respectively. Overall, incremental LOS associated with bleeding-related complications or transfusions (unadjusted for covariates) was 6.0 days and ranged from 1.3 to 9.6 days for knee/hip replacement and non-cardiac thoracic, respectively. The incremental cost per hospitalization associated with bleeding-related complications and adjusted for covariates was highest for spinal surgery ($17,279) followed by vascular ($15,123), solid organ ($13,210), non-cardiac thoracic ($13,473), cardiac ($10,279), general ($4,354), knee/hip replacement ($3,005), and reproductive organ ($2,805).

Conclusions

This study characterizes the increased hospital LOS and cost associated with bleeding-related complications and/or transfusions occurring as a consequence of surgery, and supports implementation of blood-conservation strategies.

Comparison of utilization, cost, adherence, and hypoglycemia in patients with type 2 diabetes initiating rapid-acting insulin analog with prefilled pen versus vial/syringe

BACKGROUND

Studies examining outcomes of different insulin delivery systems are limited. The objective of this study was to compare healthcare utilization, costs, adherence, and hypoglycemia rates in patients with type 2 diabetes mellitus (T2DM) initiating rapid-acting insulin analog (RAIA) using prefilled pen versus vial/syringe.

METHODS

A retrospective analysis was conducted using a US claims database (1/1/2007 to 12/31/2008). Inclusion criteria were: ≥18 years old, with T2DM, ≥12 months of continuous eligibility, and new to RAIA. Difference-in-difference analyses after propensity score matching were conducted to compare changes in outcomes from 6 months prior to and 6 months after initiating RAIA with a prefilled pen versus vial/syringe (Wilcoxon rank-sum test for costs and t-test for other outcomes). Categories of utilization and costs (2009 USD) included total and diabetes-related inpatient, outpatient, and emergency room. Adherence was measured by proportion of days covered (PDC). Hypoglycemia was identified using ICD-9-CM codes.

RESULTS

Baseline characteristics were similar between the prefilled pen (n = 239) and vial/syringe (n = 590) cohorts after matching. Adherence to RAIA was greater in the prefilled pen cohort than the vial/syringe cohort (PDC: 54.6 vs. 45.2%, p < 0.001). While the increase in diabetes-related pharmacy costs from before to after initiating RAIA was greater in the prefilled pen cohort than the vial/syringe cohort (+$900 vs. +$607, p < 0.001), the prefilled pen cohort was associated with greater reductions in the total diabetes-related costs (-$235 vs. +$61, p = 0.006) and the utilization of oral anti-hyperglycemic agents (-1.3 vs. -0.7, p = 0.016). There were no significant differences in other outcomes.

LIMITATIONS

Claims databases do not provide optimal measures for adherence or T2DM severity, and only capture hypoglycemia events requiring clinical intervention.

CONCLUSION

Initiating RAIA with a prefilled pen was associated with better adherence and greater reduction in total diabetes-related costs than a vial/syringe. There was no significant difference in total healthcare costs.

Persistence and adherence to disease modifying drugs among patients with multiple sclerosis

OBJECTIVE

This retrospective database study aimed to evaluate the adherence of multiple sclerosis (MS) patients on immunomodulatory treatments using claims data, and to identify differences between compliance and persistency measurements in the context of this disease.

METHODS

Continuously enrolled MS patients treated with subcutaneous IFNbeta-1b (Betaseron * ), subcutaneous IFNbeta-1a (Rebif dagger ), intramuscular IFNbeta-1a (Avonex double dagger ), and subcutaneous glatiramer acetate (Copaxone section sign ).) were identified from the PharMetrics patient-centric database, and all information related to patient demographics and pharmacy claims for the drugs of interest were extracted.

OUTCOME MEASURES

The main outcomes were treatment switches and discontinuations for patients initiated on the drugs of interest. Various compliance and persistency metrics including the proportion of days covered, treatment prevalence at 6-monthly time points after initiation, and the continuous time on drug were also examined.

RESULTS

A total of 6134 MS patients were started on one of the four drugs of interest. The number of patients switching or discontinuing therapy rose over the study period. The proportion of patients switching was similar between study drugs, by the different metrics, with the highest switch rates for subcutaneous IFNbeta-1b and the lowest for subcutaneous glatiramer acetate. Discontinuation rates were highest for subcutaneous IFNbeta-1b and lowest for intramuscular IFNbeta-1a. Regression models showed that intramuscular IFNbeta-1a and subcutaneous IFNbeta-1a had similar and higher persistency compared to subcutaneous IFNbeta-1b and subcutaneous glatiramer acetate.

CONCLUSIONS

Although treatment switching and discontinuation is common in MS patients, there is some noticeable variability between drugs and across measures of persistency and adherence. Also, claims data do not allow distinguishing between clinical patterns of MS, direct estimation of disease severity and observation of care that occurs outside of insurance coverage, and results need to be cautiously interpreted. The compliance to the various MS drugs was 80% or higher at all times for all four drugs. The highest rate of treatment persistency existed in the intramuscular IFNbeta-1a initiator group, while subcutaneous IFNbeta-1b was associated with a significantly lower persistence (p < 0.0001).

Healthcare resource utilization following switch or discontinuation in multiple sclerosis patients on disease modifying drugs

OBJECTIVE

The objective of this study was to explore the cost and utilization in the period following discontinuations or switches of disease modifying drugs (DMDs) for patients with multiple sclerosis (MS). Secondary objectives included an assessment of the time to switch or discontinuation from index DMD treatment.

METHODS

Cases were defined as a billed MS diagnosis in continuously enrolled patients initiated with interferon-beta1a IM, interferon-beta1b SC, glatiramer acetate, and interferon-beta1a SC found in the PharMetrics Patient-Centric Database. Information on patient demographics, diagnoses, procedures, pharmacy-dispensed drugs, and costs was extracted; reasons for discontinuation and expenses outside of the healthcare system were not available. Treatment discontinuations and switches between study drugs were defined using pharmacy prescription patterns and analyzed by descriptive and regression methods. The non-pharmacy medical costs in the 18 months following switching or discontinuation were compared to the costs in a randomly selected similar period for those patients who did not switch or discontinue these agents.

RESULTS

A total of 5,772 MS patients were continuously enrolled and were treated with one or more of the four drugs of interest, and about half of these patients switched drugs or discontinued treatment for at least 90 days. Patients initiated with interferon-beta1b SC were more likely to discontinue treatment compared to interferon-beta1a IM users. Non-pharmaceutical medical costs were highest for those switching treatments followed by those discontinuing DMDs in the 18 months following a switch or discontinuation, compared to persistent users of these drugs. Interferon beta1b SC initiators had higher costs following changes or discontinuations, while glatiramer acetate and interferon-beta1a SC users had lower subsequent costs compared to interferon-beta1a IM users.

LIMITATIONS

Unfortunately, the reasons for stopping the initial treatment cannot be determined from analysis of an administrative claims database. Also, the MS cases followed in this analysis are billing diagnostic events unconfirmed through a review of medical records or other data sources. The results are unstratified in terms of severity and thus while treatment patterns may vary for patients with different types of MS (e.g., progressive vs. relapsing-remitting), this cannot be examined in this analysis.

CONCLUSION

Changing or discontinuing DMDs is common among MS patients and is associated with higher non-pharmaceutical medical costs that vary based on the initiating drug and other demographics characteristics.

Topical bovine thrombin and adverse events: a review of the literature

OBJECTIVE

To review published evidence suggesting a link between topical bovine thrombin (TBT) and important adverse events (AEs).

RESEARCH DESIGN AND METHODS

English language articles and abstracts were obtained from MEDLINE using combinations of text and MeSH terms for thrombin, bovine thrombin and their trade names. References from summary articles were also retrieved. Published case reports, review articles, and retrospective, prospective or observational studies involving either immunogenicity or AEs were selected for further assessment. Retrieved articles were evaluated separately as AE case reports, quantitative studies of antibodies, or quantitative studies of AEs.

MAIN OUTCOME MEASURES

Presence of case causal information, temporal pattern of case report publication, reproducibility of aggregate data findings, and study design features.

RESULTS

The major limitations of reviewed publications were insufficient information regarding TBT and other exposures, and designs in which linkage between laboratory immune phenomena and AEs could not be evaluated. While immunogenicity studies did support an increased risk for post-TBT antibodies, there was no consistent evidence that this led to an increased AE risk or severity. Common evidentiary deficiencies included case reports from high incidence environments, studies of combination or mixture products, biased study designs, lack of patient-level exposure data, inadequate control groups and insufficient sample sizes. The best designed study (a randomized, controlled comparison of TBT to a recombinant bovine product) documented post-TBT antibody production, but no important efficacy or AE differences. An examination of publication dates for case reports showed a peak between 1992 and 1994 followed by a substantial drop. Since 1997 the number of published AE case reports has continued to decline.

CONCLUSIONS

TBT increases the risk for antibody elevations in patients. A careful review of published evidence does not show that either TBT itself or any associated elevations in anti-bovine antibodies are risk factors for clinically important AEs.

Pregnancy outcomes in women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts

PURPOSE

To conduct a systematic review and meta-analysis to quantify the incidence of congenital malformations (CMs) and other pregnancy outcomes as a function of in utero anti-epileptic drug (AED) exposure.

METHODS

We performed a systematic literature review to identify all published registries and cohort studies of births from pregnant women with epilepsy (WWE) that reported incidence of CMs. Overall incidences were calculated using a random effects model.

RESULTS

The review included 59 studies that met inclusion/exclusion criteria, involving 65,533 pregnancies in WWE and 1,817,024 in healthy women. The calculated incidence of births with CM in WWE [7.08%; 95% CIs 5.62, 8.54] was higher than healthy women [2.28%; CIs 1.46, 3.10]. Incidence was highest for AED polytherapy [16.78%; CIs 0.51, 33.05]. The AED with the highest CM incidence was valproate, which was 10.73% [CIs 8.16, 13.29] for valproate monotherapy.

CONCLUSIONS

Results of this systematic literature review suggest that the overall incidence of CMs in children born of WWE is approximately threefold that of healthy women. The risk is elevated for all AED monotherapy and further elevated for AED polytherapy compared to women without epilepsy. The risk was significantly higher for children exposed to valproate monotherapy and to polytherapy of 2 or more drugs when the polytherapy combination included phenobarital, phenytoin, or valproate. Further research is needed to delineate the specific risk for each individual AED and to determine underlying mechanisms including genetic risk factors.

Risk of bleeding in surgical patients treated with topical bovine thrombin sealants: a review of the literature

BACKGROUND

One of the most anticipated, but potentially serious complications during or after surgery are bleeding events. Among the many potential factors associated with bleeding complications in surgery, the use of bovine thrombin has been anecdotally identified as a possible cause of increased bleeding risk. Most of these reports of bleeding events in association with the use of topical bovine thrombin have been limited to case reports lacking clear cause and effect relationship determination. Recent studies have failed to establish significant differences in the rates of bleeding events between those treated with bovine thrombin and those treated with either human or recombinant thrombin.

METHODS

We conducted a search of MEDLINE for the most recent past 10 years (1997-2007) and identified all published studies that reported a study of surgical patients with a clear objective to examine the risk of bleeding events in surgical patients. We also specifically noted the reporting of any topical bovine thrombin used during surgical procedures. We aimed to examine whether there were any differences in the risk of bleeds in general surgical populations as compared to those studies that reported exposure to topical bovine thrombin.

RESULTS

We identified 21 clinical studies that addressed the risk of bleeding in surgery. Of these, 5 studies analyzed the use of bovine thrombin sealants in surgical patients. There were no standardized definitions for bleeding events employed across these studies. The rates of bleeds in the general surgery studies ranged from 0.1%-20.2%, with most studies reporting rates between 2.6%-4%. The rates of bleeding events ranged from 0.0%-13% in the bovine thrombin studies with most studies reporting between a 2%-3% rate.

CONCLUSION

The risk of bleeds was not clearly different in those studies reporting use of bovine thrombin in all patients compared to the other surgical populations studied. A well-designed and well-controlled study is needed to accurately examine the bleeding risks in surgical patients treated and unexposed to topical bovine thrombin, and to evaluate the independent risk associated with topical bovine thrombin as well as other risk factors.

Impact of clinical trial design and execution-related factors on incidence of thromboembolic events in cancer patients: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to quantify the incidence of thromboembolic events (specifically, deep vein thromboses [DVT] and pulmonary embolism [PE]) in patients with cancer, and to examine the effects of a major clinical trial design and execution factors on those incidence rates.

RESEARCH DESIGN AND METHODS

The study included a systematic review of Medline, Current Contents, and accepted study bibliographies, as well as an analysis of studies. Studies included both longitudinal studies (prospective and retrospective) published in the English language between January 1990 and October 2005. Studies of patients with cancer that reported the incidence of thromboembolic events (DVT, PE, and total venous thromboembolic events [VTE]) were eligible for inclusion. Incidence of these events was calculated by study design, surveillance type (active or passive), length of follow-up, and other treatment risk factors. Incidence rates were estimated by random effects Poisson meta-regression modeling.

RESULTS

One hundred and eighty-three studies met all inclusion criteria. Incidence rates of all outcomes (DVT, PE, and total VTE) were 3-55 times higher for active surveillance than for passive surveillance. Studies with a follow-up time </= 6 months reported thromboembolic event rates that were 3-26 times higher than study groups with a follow-up time > 6 months. Additionally, the incidence rates for all outcome events when using passive surveillance were 3-12 times higher in non-randomized clinical trials (non-RCTs) than in RCTs.

CONCLUSIONS

These results provide a benchmark for the incidence of thromboembolic events in patients with cancer. Factors such as study design, length of follow-up, and method of case ascertainment (type of surveillance - active or passive) must be considered when interpreting thromboembolic incidence rates. This review is comprehensive in its inclusion of all studies with a scientific objective of examining the risk of thromboembolic events in patients with cancer from 1990 to 2005. However, other studies published prior to 1990, more recently than 2005, or with other scientific objectives in their research may also provide supportive information to these risk estimates.

The experience of sexual assault: findings from a statewide victim needs assessment

A statewide assessment was conducted of assaults, experiences, needs, and recommendations of 125 adult victims receiving care at 19 sexual assault centers (SACs) in the State of Maryland. More than one half of the victims (55.6%) waited years before disclosing, with delays in reporting especially likely if the assault was perpetrated by a family member (the most frequent perpetrators at 42.4% of respondents). About one half of the victims (51.3%) had been previously sexually assaulted, yet only 9% of these victims had sought treatment. The majority of respondents (69.4%) indicated they would not be filing charges against perpetrators, and of those who did, 46.2% reported dissatisfaction with the interview with police. Psychological symptoms such as depression and anxiety were the most common reasons for seeking care at the centers. Nearly all of respondents rated the care they received at the centers as very good or excellent. Respondents recommended more SACs, better advertising of their services, more mental health care within them (especially group therapy), and improved laws and law enforcement of perpetrators.