Risk of Arterial and Venous Thrombotic Events Among Patients with COVID-19: A Multi-National Collaboration of Regulatory Agencies from Canada, Europe, and United States

Purpose

Few studies have examined how the absolute risk of thromboembolism with COVID-19 has evolved over time across different countries. Researchers from the European Medicines Agency, Health Canada, and the United States (US) Food and Drug Administration established a collaboration to evaluate the absolute risk of arterial (ATE) and venous thromboembolism (VTE) in the 90 days after diagnosis of COVID-19 in the ambulatory (eg, outpatient, emergency department, nursing facility) setting from seven countries across North America (Canada, US) and Europe (England, Germany, Italy, Netherlands, and Spain) within periods before and during COVID-19 vaccine availability.

Patients and Methods

We conducted cohort studies of patients initially diagnosed with COVID-19 in the ambulatory setting from the seven specified countries. Patients were followed for 90 days after COVID-19 diagnosis. The primary outcomes were ATE and VTE over 90 days from diagnosis date. We measured country-level estimates of 90-day absolute risk (with 95% confidence intervals) of ATE and VTE.

Results

The seven cohorts included 1,061,565 patients initially diagnosed with COVID-19 in the ambulatory setting before COVID-19 vaccines were available (through November 2020). The 90-day absolute risk of ATE during this period ranged from 0.11% (0.09-0.13%) in Canada to 1.01% (0.97-1.05%) in the US, and the 90-day absolute risk of VTE ranged from 0.23% (0.21-0.26%) in Canada to 0.84% (0.80-0.89%) in England. The seven cohorts included 3,544,062 patients with COVID-19 during vaccine availability (beginning December 2020). The 90-day absolute risk of ATE during this period ranged from 0.06% (0.06-0.07%) in England to 1.04% (1.01-1.06%) in the US, and the 90-day absolute risk of VTE ranged from 0.25% (0.24-0.26%) in England to 1.02% (0.99-1.04%) in the US.

Conclusion

There was heterogeneity by country in 90-day absolute risk of ATE and VTE after ambulatory COVID-19 diagnosis both before and during COVID-19 vaccine availability.

Impaired action-safety learning and excessive relief during avoidance in patients with anxiety disorders

Anxiety-related disorders are characterized by high levels of avoidance, but experimental research into avoidance learning in patients is scarce. To fill this gap, we compared healthy controls (HC, n = 47) with patients with obsessive-compulsive disorder (OCD, n = 33), panic disorder with agoraphobia (PDA, n = 40), and post-traumatic stress disorder (PTSD, n = 66) in a computer-based avoidance learning task, in order to examine (1) differences in rates of avoidance responses, (2) differences in action-safety learning during avoidance, and (3) differences in subjective relief following successful avoidance. The task comprised aversive negative pictures (unconditional stimulus, US) that followed pictures of two colored lamps (conditional stimuli, CS+), but not a third colored lamp (safety stimulus, CS-), and could be avoided by pressing a button during one CS+ (CS+ avoidable) but not the other (CS+ unavoidable). Participants rated their US-expectancy and level of relief on a trial-by-trial basis. Compared to the HC group, patient groups displayed higher levels of avoidance to the safety stimulus, and higher levels of US-expectancy and relief following the safety and avoidable danger stimulus. We propose that patients with anxiety disorders have low confidence in the safety consequences of avoidance actions, which induces increased relief during US omissions that reinforce the avoidance action.

Priority III: top 10 rapid review methodology research priorities identified using a James Lind Alliance Priority Setting Partnership

OBJECTIVES

A rapid review is a form of evidence synthesis considered a resource-efficient alternative to the conventional systematic review. Despite a dramatic rise in the number of rapid reviews commissioned and conducted in response to the coronavirus disease 2019 pandemic, published evidence on the optimal methods of planning, doing, and sharing the results of these reviews is lacking. The Priority III study aimed to identify the top 10 unanswered questions on rapid review methodology to be addressed by future research.

STUDY DESIGN AND SETTING

A modified James Lind Alliance Priority Setting Partnership approach was adopted. This approach used two online surveys and a virtual prioritization workshop with patients and the public, reviewers, researchers, clinicians, policymakers, and funders to identify and prioritize unanswered questions.

RESULTS

Patients and the public, researchers, reviewers, clinicians, policymakers, and funders identified and prioritized the top 10 unanswered research questions about rapid review methodology. Priorities were identified throughout the entire review process, from stakeholder involvement and formulating the question, to the methods of a systematic review that are appropriate to use, through to the dissemination of results.

CONCLUSION

The results of the Priority III study will inform the future research agenda on rapid review methodology. We hope this will enhance the quality of evidence produced by rapid reviews, which will ultimately inform decision-making in the context of healthcare.

Comparative-effectiveness research of COVID-19 treatment: a rapid scoping review

OBJECTIVES

The COVID-19 pandemic has stimulated growing research on treatment options. We aim to provide an overview of the characteristics of studies evaluating COVID-19 treatment.

DESIGN

Rapid scoping review DATA SOURCES: Medline, Embase and biorxiv/medrxiv from inception to 15 May 2021.

SETTING

Hospital and community care.

PARTICIPANTS

COVID-19 patients of all ages.

INTERVENTIONS

COVID-19 treatment.

RESULTS

The literature search identified 616 relevant primary studies of which 188 were randomised controlled trials and 299 relevant evidence syntheses. The studies and evidence syntheses were conducted in 51 and 39 countries, respectively.Most studies enrolled patients admitted to acute care hospitals (84%), included on average 169 participants, with an average age of 60 years, study duration of 28 days, number of effect outcomes of four and number of harm outcomes of one. The most common primary outcome was death (32%).The included studies evaluated 214 treatment options. The most common treatments were tocilizumab (11%), hydroxychloroquine (9%) and convalescent plasma (7%). The most common therapeutic categories were non-steroidal immunosuppressants (18%), steroids (15%) and antivirals (14%). The most common therapeutic categories involving multiple drugs were antimalarials/antibiotics (16%), steroids/non-steroidal immunosuppressants (9%) and antimalarials/antivirals/antivirals (7%). The most common treatments evaluated in systematic reviews were hydroxychloroquine (11%), remdesivir (8%), tocilizumab (7%) and steroids (7%).The evaluated treatment was in favour 50% and 36% of the evaluations, according to the conclusion of the authors of primary studies and evidence syntheses, respectively.

CONCLUSIONS

This rapid scoping review characterised a growing body of comparative-effectiveness primary studies and evidence syntheses. The results suggest future studies should focus on children, elderly ≥65 years of age, patients with mild symptoms, outpatient treatment, multimechanism therapies, harms and active comparators. The results also suggest that future living evidence synthesis and network meta-analysis would provide additional information for decision-makers on managing COVID-19.

What are the most important unanswered research questions on rapid review methodology? A James Lind Alliance research methodology Priority Setting Partnership: the Priority III study protocol

Background: The value of rapid reviews in informing health care decisions is more evident since the onset of the coronavirus disease 2019 (COVID-19) pandemic. While systematic reviews can be completed rapidly, rapid reviews are usually a type of evidence synthesis in which components of the systematic review process may be simplified or omitted to produce information more efficiently within constraints of time, expertise, funding or any combination thereof. There is an absence of high-quality evidence underpinning some decisions about how we plan, do and share rapid reviews. We will conduct a modified James Lind Alliance Priority Setting Partnership to determine the top 10 unanswered research questions about how we plan, do and share rapid reviews in collaboration with patients, public, reviewers, researchers, clinicians, policymakers and funders. Methods: An international steering group consisting of key stakeholder perspectives (patients, the public, reviewers, researchers, clinicians, policymakers and funders) will facilitate broad reach, recruitment and participation across stakeholder groups. An initial online survey will identify stakeholders' perceptions of research uncertainties about how we plan, do and share rapid reviews. Responses will be categorised to generate a long list of questions. The list will be checked against systematic reviews published within the past three years to identify if the question is unanswered. A second online stakeholder survey will rank the long list in order of priority. Finally, a virtual consensus workshop of key stakeholders will agree on the top 10 unanswered questions. Discussion: Research prioritisation is an important means for minimising research waste and ensuring that research resources are targeted towards answering the most important questions. Identifying the top 10 rapid review methodology research priorities will help target research to improve how we plan, do and share rapid reviews and ultimately enhance the use of high-quality synthesised evidence to inform health care policy and practice.

What are the most important unanswered research questions on rapid review methodology? A James Lind Alliance research methodology Priority Setting Partnership: the Priority III study protocol

Background: The value of rapid reviews in informing health care decisions is more evident since the onset of the coronavirus disease 2019 (COVID-19) pandemic. While systematic reviews can be completed rapidly, rapid reviews are usually a type of evidence synthesis in which components of the systematic review process may be simplified or omitted to produce information more efficiently within constraints of time, expertise, funding or any combination thereof. There is an absence of high-quality evidence underpinning some decisions about how we plan, do and share rapid reviews. We will conduct a modified James Lind Alliance Priority Setting Partnership to determine the top 10 unanswered research questions about how we plan, do and share rapid reviews in collaboration with patients, public, reviewers, researchers, clinicians, policymakers and funders. Methods: An international steering group consisting of key stakeholder perspectives (patients, the public, reviewers, researchers, clinicians, policymakers and funders) will facilitate broad reach, recruitment and participation across stakeholder groups. An initial online survey will identify stakeholders' perceptions of research uncertainties about how we plan, do and share rapid reviews. Responses will be categorised to generate a long list of questions. The list will be checked against systematic reviews published within the past three years to identify if the question is unanswered. A second online stakeholder survey will rank the long list in order of priority. Finally, a virtual consensus workshop of key stakeholders will agree on the top 10 unanswered questions. Discussion: Research prioritisation is an important means for minimising research waste and ensuring that research resources are targeted towards answering the most important questions. Identifying the top 10 rapid review methodology research priorities will help target research to improve how we plan, do and share rapid reviews and ultimately enhance the use of high-quality synthesised evidence to inform health care policy and practice.

[Intensive, short-term treatment for adolescents with persevering obsessive-compulsive disorder: three case-reports]

Approximately 40% of adolescents with obsessive-compulsive disorder (ocd) do not improve sufficiently from standard cognitive behavioral therapy, and are at risk for a chronic course of the symptomatology as well as stagnation in their development. There has hardly been any research into next step evidence-based treatments for adolescents with persevering ocd. We treated three adolescents with persevering ocd with an eight-day intensive, therapist-assisted exposure and response prevention (erp) in which family members were involved. Two out of the three patients showed an improvement in ocd-symptoms and for one of these two patients the symptoms went in full remission. These outcomes are promising, and these case studies prove that short erp therapy, which is more intensive and provides assisted erp, can be a possible second step in the treatment.

"It's on everyone's plate": a qualitative study into physicians' perceptions of responsibility for smoking cessation

BACKGROUND

Little research has investigated in-depth how physicians perceive their role in smoking cessation care. This qualitative study sought to understand physicians' perceptions of responsibility for smoking cessation.

METHODS

Data were collected through individual semi-structured interviews and focus group interviews between June and November 2017 in The Netherlands. We interviewed 5 addiction specialists, 5 anesthesiologist, 4 cardiologists, 8 GPs, 5 internists, 5 neurologists, 2 pediatricians, 6 pulmonologists, 7 surgeons, and 8 youth healthcare physicians (N = 55). Data analysis followed the framework approach.

RESULTS

The analysis showed that three actors were perceived as responsible for smoking cessation: physicians, patients, and the government. Participants perceived physicians as responsible for facilitating smoking cessation -albeit to different extents-, patients as carrying the ultimate responsibility for quitting smoking, and the government as responsible for creating a society in which smoking uptake is more difficult and quitting smoking easier. Perceptions of smoking itself were found to be important for how participants viewed responsibility for smoking cessation. It remained unclear for many participants which healthcare provider is responsible for smoking cessation care.

CONCLUSIONS

The organization of smoking cessation care within health systems should be a focus of intervention, to better define physician roles and perceptions of responsibility. In addition, it seems important to target perceptions of smoking itself on the level of physicians and -as suggested by comments by several participants- the government.

[An exploratory study of 'blended' cognitive behavioural therapy (CBT) for patients with a panic disorder: results and patients' experiences]

BACKGROUND

Digital technology (e-health or 'blended' care), combined with evidence-based face-to-face CBT, is becoming increasingly implemented into mental health care and is expected to result in improved effectiveness and efficiency.

AIM

To explore the feasibility of blended CBT for patients with a panic disorder.

METHOD

Nine face-to-face sessions of blended CBT (n = 18), supplemented with the digital support of a tabletcomputer and three e-mail contacts, were compared with 12 weekly sessions of regular CBT (n = 18). Primary outcomes were panic frequency and avoidance behaviour; the secondary outcome was general functioning. Patients' experiences of the treatment were collected in the form of a structured interview.

RESULTS

The effect sizes found in both the regular and the blended CBT were medium to high (Cohen's d 0.42-1.60). In both types of treatment there was a significant reduction in patients' symptoms. There were no big differences in patient satisfaction regarding the treatment received. The therapists registered 39 face-to-face minutes in the blended treatment but they registered in total 41 fewer face-to-face minutes; this represented a time reduction of 4%.

CONCLUSION

Blended CBT with help of a tablet computer seems to be a suitable method for treating panic disorder psychologically, although the time saved is only moderate. Much more research is needed to ascertain the feasibility and the cost effectiveness of blended CBT.

[Treatment of anxiety disorders in the elderly]

AIM

To collect empirical evidence concerning the effectiveness of the treatment of anxiety disorders in the elderly.

METHOD

Meta-analysis and randomised controlled trials.

RESULTS

Meta-analysis showed that cognitive behavioural therapy (CBT) was more successful than waiting-list control or active control as a treatment for older persons with anxiety disorders. In a direct comparison of the treatment of older persons with panic disorder (PD) both CBT an paroxetine were found to be more effective than waiting-list control. CBT was more successful in reducing avoidance behaviours in older persons with PD. Older persons with reported fewer and less severe agoraphobic cognitions than younger patients, but there was no difference between the severity of agoraphobic avoidance in older patients with PD and younger patients with PD.

CONCLUSION

There is sufficient empirical evidence to support the effectiveness of CBT in the treatment of older persons with anxiety disorders. In assessing the severity of PD in the elderly, one should carefully consider the severity of avoidance behaviours. Because no difference was found between the effectiveness of CBT and paroxetine for the treatment of PD in the elderly and because was more effective in reducing avoidance behaviours in older patients with PD than in younger patients with pd, there seems to be a slight preference for CBT in the case of older patients with PD. Older age is not associated with a poorer outcome of treatment with CBT.

Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine

OBJECTIVE

Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behaviour therapy (CBT) have both proven to be effective in the treatment of obsessive compulsive disorder (OCD). It is generally recommended that adequate but unsuccessful SSRI treatment is supplemented with CBT, although only one empirical study was conducted to verify this recommendation. The present study examined the effects of supplemental CBT to continued fluoxetine treatment in OCD patients non-responding to fluoxetine alone.

METHOD

After 12 weeks of fluoxetine, 14 of 56 out-patients had a reduction rate less than 25% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and were classified as non-responders. They subsequently received 12 sessions CBT additional to the continued fluoxetine treatment.

RESULTS

The mean symptom reduction as rated by the Y-BOCS, for the patients who completed both treatment phases, was 8.5% in the first phase and 41% in the second phase.

CONCLUSION

Supplemental CBT for OCD patients, after initial, unsuccessful fluoxetine treatment is shown to be effective.

An experimental test of the relationship between self-esteem and concern about body shape and weight in restrained eaters

OBJECTIVE

Although self-esteem and overconcern with body shape and weight are considered to be closely connected in bulimia nervosa, little empirical research has been done to investigate the alleged link.

METHOD

In this study, we examined experimentally whether overconcern with body shape and weight was connected with self-esteem in an analogue sample of high restrained eaters by means of a subliminal lexical decision task.

RESULTS

It could indeed be demonstrated that low self-esteem and overconcern with body shape and weight are associated in high restrained eaters: after priming low self-esteem, the accessibility of subliminally presented body shape and weight stimuli was increased. The effect was not found with a supraliminal lexical decision task.

DISCUSSION

Apparently, the automatic, nonconscious processing of body shape and weight words was influenced in high restrained eaters with a low state self-esteem, whereas the strategic, conscious processing was not. As soon as the body shape and weight stimuli were processed consciously, the initial increased accessibility was countered and the effect disappeared.