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Jansen MS, Dekkers OM, le Cessie S, Hooft L, Gardarsdottir H, de Boer A, Groenwold RHH. Real-World Evidence to Inform Regulatory Decision Making: A Scoping Review. Clin Pharmacol Ther 2024; 115:1269-1276. [PMID: 38390633 DOI: 10.1002/cpt.3218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
Real-world evidence (RWE) is increasingly considered in regulatory decision making. When, and to which extent, RWE is considered relevant by regulators likely depends on many factors. This review aimed to identify factors that make RWE necessary or desirable to inform regulatory decision making. A scoping review was conducted using literature databases (PubMed, Embase, Emcare, Web of Science, and Cochrane Library) and websites of regulatory agencies, health technology assessment agencies, research institutes, and professional organizations involved with RWE. Articles were included if: (1) they discussed factors or contexts that impact whether RWE could be necessary or desirable in regulatory decision making; (2) focused on pharmacological or biological interventions in humans; and (3) considered decision making in Europe or North America, or without a focus on a specific region. We included 118 articles in the scoping review. Two major themes and six subthemes were identified. The first theme concerns questions addressable with RWE, with subthemes epidemiology and benefit-risk assessment. The second theme concerns contextual factors, with subthemes feasibility, ethical considerations, limitations of available evidence, and disease and treatment-specific aspects. Collectively, these themes encompassed 43 factors influencing the need for RWE in regulatory decisions. Although single factors may not make RWE fully necessary, their cumulative influence could make RWE essential and pivotal in regulatory decision making. This overview contributes to ongoing discussions emphasizing the nuanced interplay of factors influencing the necessity or desirability of RWE to inform regulatory decision making.
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Affiliation(s)
- Marieke S Jansen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology and Metabolic Disorders, Leiden University Medical Center, Leiden, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University Utrecht, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
| | - Anthonius de Boer
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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Cherenko M, Appelman-Dijkstra NM, Priego Zurita AL, Biermasz NR, Dekkers OM, Klok FA, Reisch N, Aulinas A, Biagetti B, Cannavo S, Canu L, Detomas M, Devuyst F, Falhammar H, Feelders RA, Ferrau F, Gatto F, Grasselli C, van Houten P, Hoybye C, Isidori AM, Kyrilli A, Loli P, Maiter D, Nowak E, Pivonello R, Ragnarsson O, Steenaard RV, Unger N, van de Ven A, Webb SM, Yeste D, Ahmed SF, Pereira AM. Venous thromboembolism in Cushing syndrome: results from an EuRRECa and Endo-ERN survey. Endocr Connect 2024; 13:e240046. [PMID: 38614126 PMCID: PMC11103746 DOI: 10.1530/ec-24-0046] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/11/2024] [Indexed: 04/15/2024]
Abstract
Background Patients with Cushing syndrome (CS) are at increased risk of venous thromboembolism (VTE). Objective The aim was to evaluate the current management of new cases of CS with a focus on VTE and thromboprophylaxis. Design and methods A survey was conducted within those that report in the electronic reporting tool (e-REC) of the European Registries for Rare Endocrine Conditions (EuRRECa) and the involved main thematic groups (MTG's) of the European Reference Networks for Rare Endocrine Disorders (Endo-ERN) on new patients with CS from January 2021 to July 2022. Results Of 222 patients (mean age 44 years, 165 females), 141 patients had Cushing disease (64%), 69 adrenal CS (31%), and 12 patients with ectopic CS (5.4%). The mean follow-up period post-CS diagnosis was 15 months (range 3-30). Cortisol-lowering medications were initiated in 38% of patients. One hundred fifty-four patients (69%) received thromboprophylaxis (including patients on chronic anticoagulant treatment), of which low-molecular-weight heparins were used in 96% of cases. VTE was reported in six patients (2.7%), of which one was fatal: two long before CS diagnosis, two between diagnosis and surgery, and two postoperatively. Three patients were using thromboprophylaxis at time of the VTE diagnosis. The incidence rate of VTE in patients after Cushing syndrome diagnosis in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Conclusion Thirty percent of patients with CS did not receive preoperative thromboprophylaxis during their active disease stage, and half of the VTE cases even occurred during this stage despite thromboprophylaxis. Prospective trials to establish the optimal thromboprophylaxis strategy in CS patients are highly needed. Significance statement The incidence rate of venous thromboembolism in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Notably, this survey showed that there is great heterogeneity regarding time of initiation and duration of thromboprophylaxis in expert centers throughout Europe.
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Affiliation(s)
- M Cherenko
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - N M Appelman-Dijkstra
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - A L Priego Zurita
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - O M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - F A Klok
- Department of Medicine, Division of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, Netherlands
| | - N Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - A Aulinas
- Department of Endocrinology, Fundacio de Gestio Sanitaria Hospital de la Santa Creu i Sant Pau, IR-SantPau and CIBERER Unit 747 (ISCIII), Barcelona, Spain
| | - B Biagetti
- Department of Endocrinology, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - S Cannavo
- Endocrine Unit, University Hospital AOU Policlinico G. Martino, Messina, Italy
| | - L Canu
- University Hospital Florence Careggi, Florence, Italy
| | - M Detomas
- Department of Internal Medicine, University Hospital Würzburg, Wuerzburg, Germany
| | - F Devuyst
- Department of Endocrinology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - H Falhammar
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - R A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Rotterdam, Netherlands
| | - F Ferrau
- Endocrine Unit, University Hospital AOU Policlinico G. Martino, Messina, Italy
| | - F Gatto
- IRCCS Ospedale Policlinico San Martino, Genova, Genoa, Italy
| | - C Grasselli
- Cardiovascular Medicine Unit, AUSL-IRCCS, Reggio Emilia, Italy
| | - P van Houten
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - C Hoybye
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Kyrilli
- Department of Endocrinology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - P Loli
- Division of Endocrinology, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital Milan, Italy
| | - D Maiter
- Department of Endocrinology, Cliniques universitaires Saint-Luc – UCLouvain, Brussels, Belgium
| | - E Nowak
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università “Federico II” di Napoli, Naples, Italy
| | - O Ragnarsson
- Sahlgrenska Academy, Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine (O.R.), University of Gothenburg, Sweden
| | - R V Steenaard
- Department of Internal Medicine, Máxima MC, Veldhoven, Netherlands
| | - N Unger
- University Hospital Essen, Department of Endocrinology, Diabetes and Metabolism, Essen, Germany
| | - A van de Ven
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - S M Webb
- Department of Endocrinology, Fundacio de Gestio Sanitaria Hospital de la Santa Creu i Sant Pau, IR-SantPau and CIBERER Unit 747 (ISCIII), Barcelona, Spain
| | - D Yeste
- Pediatric Endocrinology Service, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. CIBER Enfermedades Raras, Instituto Carlos III, Madrid, Spain
| | - S F Ahmed
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
- University of Glasgow, Office for Rare Conditions, Glasgow, UK
- University of Glasgow, Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, UK
| | - A M Pereira
- Department of Endocrinology & Metabolism, Amsterdam University Medical Centre, Amsterdam, Noord-Holland, Netherlands
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Leerling AT, Niesters M, Flendrie M, Tel M, Appelman-Dijkstra NM, Dekkers OM, Winter EM. Neuropathic and Nociplastic Pain Profiles are Common in Adult Chronic Nonbacterial Osteitis (CNO). Calcif Tissue Int 2024; 114:603-613. [PMID: 38627292 DOI: 10.1007/s00223-024-01214-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/28/2024] [Indexed: 05/14/2024]
Abstract
Chronic nonbacterial osteitis (CNO) is a rare musculoskeletal disease causing chronic bone pain. It is known that chronic musculoskeletal pain may involve other mechanisms than nociceptive pain only. We investigate the prevalence of neuropathic and nociplastic pain in adult CNO and their association with clinical characteristics and treatment outcomes. Survey study among the Dutch adult CNO cohort (n = 84/195 participated), including PAIN-detect for neuropathic pain, and the Central Sensitization Inventory (CSI), Fibromyalgia Rapid Screening Tool (FiRST), and ACTTION-APS Pain Taxonomy (AAPT) for nociplastic pain. Clinical characteristics and CNO-related bone pain scores were compared between patients with exclusive nociceptive pain and those with nociceptive pain plus neuropathic and/or nociplastic pain (mixed pain). 31% (95% CI 21-41) of patients classified as likely having neuropathic pain according to PAIN-detect. 53% (41-64) of patients displayed central sensitization on CSI, 61% (50-72) screened positive for fibromyalgia on FiRST and 14% (7-23) of patients fulfilled the AAPT criteria, all indicative of nociplastic pain. Mixed pain was associated with longer diagnostic delay (mean difference 2.8 years, 95% CI 0.4-5.2, p = 0.023), lower educational level (72% versus 20%, p < 0.001), and opioid use (37% versus 13%, p = 0.036). Despite comparable disease severity and extent, patients with mixed pain reported significantly higher CNO-related bone pain scores. This study demonstrates the high prevalence of mixed pain in adult CNO, in which neuropathic and nociplastic pain exist alongside nociceptive inflammatory bone pain. Disease burden in CNO may extend beyond inflammatory activity, highlighting the need for a multifaceted management approach.
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Affiliation(s)
- Anne T Leerling
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology and Pain Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel Flendrie
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Marije Tel
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Olaf M Dekkers
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.
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Koning ASCAM, van der Meulen M, Schaap D, Satoer DD, Vinkers CH, van Rossum EFC, van Furth WR, Pereira AM, Meijer OC, Dekkers OM. Neuropsychiatric Adverse Effects of Synthetic Glucocorticoids: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2024; 109:e1442-e1451. [PMID: 38038629 PMCID: PMC11099480 DOI: 10.1210/clinem/dgad701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/16/2023] [Accepted: 11/29/2023] [Indexed: 12/02/2023]
Abstract
CONTEXT Synthetic glucocorticoids are widely used to treat patients with a broad range of diseases. While efficacious, glucocorticoids can be accompanied by neuropsychiatric adverse effects. OBJECTIVE This systematic review and meta-analysis assesses and quantifies the proportion of different neuropsychiatric adverse effects in patients using synthetic glucocorticoids. METHODS Six electronic databases were searched to identify potentially relevant studies. Randomized controlled trials, cohort studies, and cross-sectional studies assessing psychiatric side effects of glucocorticoids measured with validated questionnaires were eligible. Risk of bias was assessed with RoB 2, ROBINS-I, and AXIS appraisal tool. For proportions of neuropsychiatric outcomes, we pooled proportions, and when possible, differences in questionnaire scores between glucocorticoid users and nonusers were expressed as standardized mean differences (SMD). Data were pooled in a random-effects logistic regression model. RESULTS We included 49 studies with heterogeneity in study populations, type, dose, and duration of glucocorticoids. For glucocorticoid users, meta-analysis showed a proportion of 22% for depression (95% CI, 14%-33%), 11% for mania (2%-46%), 8% for anxiety (2%-25%), 16% for delirium (6%-36%), and 52% for behavioral changes (42%-61%). Questionnaire scores for depression (SMD of 0.80 [95% CI 0.35-1.26]), and mania (0.78 [0.14-1.42]) were higher than in controls, indicating more depressive and manic symptoms following glucocorticoid use. CONCLUSION The heterogeneity of glucocorticoid use is reflected in the available studies. Despite this heterogeneity, the proportion of neuropsychiatric adverse effects in glucocorticoid users is high. The most substantial associations with glucocorticoid use were found for depression and mania. Upon starting glucocorticoid treatment, awareness of possible psychiatric side effects is essential. More structured studies on incidence and potential pathways of neuropsychiatric side effects of prescribed glucocorticoids are clearly needed.
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Affiliation(s)
- Anne-Sophie C A M Koning
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Merel van der Meulen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Daphne Schaap
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Djaina D Satoer
- Department of Neurosurgery, Erasmus MC—University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Christiaan H Vinkers
- Department of Psychiatry and Department of Anatomy and Neurosciences, Amsterdam University Medical Center, Location VUMC, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Academic Working Place Depression, GGZ InGeest, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands
- Amsterdam Neuroscience (Mood, Anxiety, Psychosis, Stress & Sleep Program) and Amsterdam Public Health (Mental Health Program) Research Institutes, Amsterdam, The Netherlands
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Wouter R van Furth
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospitals, Leiden and The Hague, The Netherlands
| | - Alberto M Pereira
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Meier ME, Vágó E, Abrahamsen B, Dekkers OM, Horváth-Puhó E, Rejnmark L, Appelman-Dijkstra NM. Incidence and Prevalence of Fibrous Dysplasia/McCune-Albright Syndrome: A Nationwide Registry-Based Study in Denmark. J Clin Endocrinol Metab 2024; 109:1423-1432. [PMID: 38174586 PMCID: PMC11099484 DOI: 10.1210/clinem/dgad744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/27/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024]
Abstract
CONTEXT Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare genetic disorder. Incidence and prevalence are not well-studied. Epidemiological research is complicated by the rarity of FD/MAS, absence of registries, heterogeneous presentation, and possibly asymptomatic phenotype. FD/MAS may present with FGF23-mediated hypophosphatemia, of which the epidemiology is also unclear. OBJECTIVE Evaluate incidence and prevalence of FD/MAS and FD/MAS-related hypophosphatemia. METHODS This cohort study based on the nationwide Danish National Patient Registry from 1995-2018, included patients identified by ICD-10 codes M85.0 (monostotic FD [MFD]) and Q78.1 (polyostotic FD [PFD]/MAS). Incidence rates and prevalence were calculated and stratified by sex, age, calendar period, and diagnosis code. Cases were screened for FD-associated hypophosphatemia by diagnosis code E.83 (disorder of mineral metabolism) and dispatched vitamin D analogues. RESULTS A total of 408 patients were identified, 269 with MFD (66%), 139 with PFD/MAS (34%), comparable between sexes. Incidence of FD/MAS demonstrated increasing secular trend with a rate of 3.6 per 1 000 000 person-years (95% CI: 2.9, 4.5) in 2015-2018. Incidence peaked between age 11 and 20. Prevalence of FD/MAS increased over time to 61.0 (95% CI: 54.6, 67.4) per 1 000 000 persons in 2018. The incidence rate of MFD was 1.5-fold that of PFD/MAS in the first decade, rising to 2.5-fold in the last decade. No FD/MAS cases were registered with diagnosis code or treatment for hypophosphatemia. CONCLUSION FD/MAS is rare, diagnosis peaks during adolescence without sex predominance, and MFD is most prevalent. Hypophosphatemia may be underdiagnosed and undertreated, or it may be underregistered, comparing this study to literature.
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Affiliation(s)
- Maartje E Meier
- Department of Orthopedic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Emese Vágó
- Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus N, Denmark
| | - Bo Abrahamsen
- OPEN Patient Data Explorative Network, University of Southern Denmark, 5000 Odense C, Denmark
- Department of Medicine, Holbaek Hospital, 4300 Holbaek, Denmark
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | | | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Eur J Endocrinol 2024; 190:G25-G51. [PMID: 38714321 DOI: 10.1093/ejendo/lvae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 05/09/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, Munich, Germany
- The LOOP Zurich Medical Research Center, Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic Rocheste r, MN 55905, US
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, MN 55905, US
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Dekkers OM, Groenwold RHH. [Causes of death: the uncertainty behind the numbers]. Ned Tijdschr Geneeskd 2024; 168:D8059. [PMID: 38601991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
When a person dies in the Netherlands it is legally required to report the cause of death. In most cases however, there is uncertainty when classifying causes of death. Additional postmortem diagnostics such as a CT scan or autopsy do not always provide absolute certainty. Data on causes of death can be used to determine what are, on a population level, relevant health problems. One must be cautious to fully rely on these data for making policy or financing healthcare and research. Firstly, incorrectly classifying the cause of death can give a distorted view of the underlying causes. Secondly, relevant health problems, such as obesity, might be overlooked in the statistics when they are not clearly a cause of death.
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Hustrini NM, Susalit E, Widjaja FF, Khumaedi AI, Dekkers OM, van Diepen M, Rotmans JI. The Etiology of Advanced Chronic Kidney Disease in Southeast Asia: A Meta-analysis. J Epidemiol Glob Health 2024:10.1007/s44197-024-00209-5. [PMID: 38587764 DOI: 10.1007/s44197-024-00209-5] [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] [Received: 01/10/2024] [Accepted: 02/14/2024] [Indexed: 04/09/2024] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) etiology varies greatly between developed and developing countries. In addition, differences in underlying pathogenesis and therapeutic options affect the progression towards advanced-CKD. This meta-analysis aims to identify the etiology of advanced-CKD in Southeast Asia. METHODS A systematic search in four electronic-databases and complementary search on national kidney registries and repository libraries was conducted until July 20, 2023. The risk of bias was assessed using Newcastle-Ottawa Scale for observational studies and Version-2 of Cochrane for intervention studies. A random-effects model was used to estimate pooled prevalence. The protocol is registered in the International Prospective Register of Systematic Reviews PROSPERO; Registration ID:CRD42022300786. RESULTS We analyzed 81 studies involving 32,834 subjects. The pooled prevalence of advanced-CKD etiologies are diabetic kidney disease (DKD) 29.2% (95%CI 23.88-34.78), glomerulonephritis 20.0% (95%CI 16.84-23.38), hypertension 16.8% (95%CI 14.05-19.70), other 8.6% (95%CI 6.97-10.47), unknown 7.5% (95%CI 4.32-11.50), and polycystic kidney disease 0.7% (95%CI 0.40-1.16). We found a significant increase in DKD prevalence from 21% (9.2%, 95%CI 0.00-33.01) to 30% (95%CI 24.59-35.97) before and after the year 2000. Among upper-middle-income and high-income countries, DKD is the most prevalent (26.8%, 95%CI 21.42-32.60 and 38.9%, 95%CI 29.33-48.79, respectively), while glomerulonephritis is common in lower-middle-income countries (33.8%, 95%CI 15.62-54.81). CONCLUSION The leading cause of advanced-CKD in Southeast Asia is DKD, with a substantial proportion of glomerulonephritis. An efficient screening program targeting high-risk populations (diabetes mellitus and glomerulonephritis) is needed, with the aim to delay CKD progression.
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Affiliation(s)
- Ni Made Hustrini
- Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands
| | - Endang Susalit
- Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | | | - Anandhara Indriani Khumaedi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Olaf M Dekkers
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands.
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9
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Dekkers OM, Laugesen K, Groenwold RHH. Directed acyclic graphs in clinical research. Eur J Endocrinol 2024; 190:E5-E7. [PMID: 38529789 DOI: 10.1093/ejendo/lvae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/21/2024] [Accepted: 03/01/2024] [Indexed: 03/27/2024]
Abstract
Directed acyclic graphs (DAGs), or causal diagrams, are graphical representations of causal structures that can be used in medical research to understand and illustrate potential bias, including bias arising from confounding, selection, and misclassification. Further, they provide guidance for researchers about how to address a potential bias.
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Affiliation(s)
- Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, 2300RC Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Endocrinology, Leiden University Medical Center, 2300RC Leiden, The Netherlands
| | - Kristina Laugesen
- Department of Clinical Epidemiology, Aarhus University, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Clinical Biochemistry, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, 2300RC Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2300RC Leiden, The Netherlands
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10
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Mulatero P, Scholl UI, Fardella CE, Charmandari E, Januszewicz A, Reincke M, Gomez-Sanchez CE, Stowasser M, Dekkers OM. Familial hyperaldosteronism: an European Reference Network on Rare Endocrine Conditions clinical practice guideline. Eur J Endocrinol 2024; 190:G1-G14. [PMID: 38571460 DOI: 10.1093/ejendo/lvae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
We describe herein the European Reference Network on Rare Endocrine Conditions clinical practice guideline on diagnosis and management of familial forms of hyperaldosteronism. The guideline panel consisted of 10 experts in primary aldosteronism, endocrine hypertension, paediatric endocrinology, and cardiology as well as a methodologist. A systematic literature search was conducted, and because of the rarity of the condition, most recommendations were based on expert opinion and small patient series. The guideline includes a brief description of the genetics and molecular pathophysiology associated with each condition, the patients to be screened, and how to screen. Diagnostic and treatment approaches for patients with genetically determined diagnosis are presented. The recommendations apply to patients with genetically proven familial hyperaldosteronism and not to families with more than one case of primary aldosteronism without demonstration of a responsible pathogenic variant.
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Affiliation(s)
- Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126 Torino, Italy
| | - Ute I Scholl
- Center of Functional Genomics, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Carlos E Fardella
- Department of Endocrinology, School of Medicine, Centro Traslacional de Endocrinología Universidad Católica (CETREN-UC), Pontificia Universidad Católica de Chile, 8330033 Santiago, Chile
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Athens 11527, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens 11527, Greece
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, 02-628 Warsaw, Poland
| | - Martin Reincke
- Department of Medicine 4, LMU University Hospital, LMU Munich, Munich D-80336, Germany
| | - Celso E Gomez-Sanchez
- Research Service, G. V. (Sonny) Montgomery VA Medical Center, Jackson, MS 39216, United States
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, 39216 MS, United States
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Frazer Institute, Greenslopes and Princess Alexandra Hospitals, Brisbane, 4102 Queensland, Australia
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Centre, 2311 Leiden, The Netherlands
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11
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van der Spoel E, van Vliet NA, Poortvliet RKE, Du Puy RS, den Elzen WPJ, Quinn TJ, Stott DJ, Sattar N, Kearney PM, Blum MR, Alwan H, Rodondi N, Collet TH, Westendorp RGJ, Ballieux BE, Jukema JW, Dekkers OM, Gussekloo J, Mooijaart SP, van Heemst D. Incidence and Determinants of Spontaneous Normalization of Subclinical Hypothyroidism in Older Adults. J Clin Endocrinol Metab 2024; 109:e1167-e1174. [PMID: 37862463 PMCID: PMC10876405 DOI: 10.1210/clinem/dgad623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/29/2023] [Accepted: 10/18/2023] [Indexed: 10/22/2023]
Abstract
CONTEXT With age, the prevalence of subclinical hypothyroidism rises. However, incidence and determinants of spontaneous normalization remain largely unknown. OBJECTIVE To investigate incidence and determinants of spontaneous normalization of TSH levels in older adults with subclinical hypothyroidism. DESIGN Pooled data were used from the (1) pretrial population and (2) in-trial placebo group from 2 randomized, double-blind, placebo-controlled trials (Thyroid Hormone Replacement for Untreated Older Adults With Subclinical Hypothyroidism Trial and Institute for Evidence-Based Medicine in Old Age thyroid 80-plus thyroid trial). SETTING Community-dwelling 65+ adults with subclinical hypothyroidism from the Netherlands, Switzerland, Ireland, and the United Kingdom. PARTICIPANTS The pretrial population (N = 2335) consisted of older adults with biochemical subclinical hypothyroidism, defined as ≥1 elevated TSH measurement (≥4.60 mIU/L) and a free T4 within the laboratory-specific reference range. Individuals with persistent subclinical hypothyroidism, defined as ≥2 elevated TSH measurements ≥3 months apart, were randomized to levothyroxine/placebo, of which the in-trial placebo group (N = 361) was included. MAIN OUTCOME MEASURES Incidence of spontaneous normalization of TSH levels and associations between participant characteristics and normalization. RESULTS In the pretrial phase, TSH levels normalized in 60.8% of participants in a median follow-up of 1 year. In the in-trial phase, levels normalized in 39.9% of participants after 1 year of follow-up. Younger age, female sex, lower initial TSH level, higher initial free T4 level, absence of thyroid peroxidase antibodies, and a follow-up measurement in summer were independent determinants for normalization. CONCLUSION Because TSH levels spontaneously normalized in a large proportion of older adults with subclinical hypothyroidism (also after confirmation by repeat measurement), a third measurement may be recommended before considering treatment. TRIAL REGISTRATION ClinicalTrials.gov, NCT01660126 and Netherlands Trial Register, NTR3851.
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Affiliation(s)
- Evie van der Spoel
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Nicolien A van Vliet
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Robert S Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Wendy P J den Elzen
- Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Public Health Research Institute, 1081 HV Amsterdam, The Netherlands
| | - Terence J Quinn
- Department of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G4 0SF, UK
| | - David J Stott
- Department of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G4 0SF, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Patricia M Kearney
- School of Public Health, University College Cork, Cork T12 K8AF, Ireland
| | - Manuel R Blum
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3008 Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, 3012 Bern, Switzerland
| | - Heba Alwan
- Institute of Primary Health Care (BIHAM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Tinh-Hai Collet
- Service of Endocrinology, Diabetes, Nutrition and Therapeutic Education, Department of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
- Diabetes Centre, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland
| | - Rudi G J Westendorp
- Department of Public Health, University of Copenhagen, 1353 Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Bart E Ballieux
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Olaf M Dekkers
- Department of Internal Medicine, Section of Endocrinology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Diana van Heemst
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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12
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Rosendal C, Arlien-Søborg MC, Nielsen EH, Andersen MS, Feltoft CL, Kistorp C, Dekkers OM, Jørgensen JOL, Dal J. The changing landscape of acromegaly - an epidemiological perspective. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09875-z. [PMID: 38337125 DOI: 10.1007/s11154-024-09875-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 02/12/2024]
Abstract
Acromegaly is a rare disease and thus challenging to accurately quantify epidemiologically. In this comprehensive literature review, we compare different approaches to studying acromegaly from an epidemiological perspective and describe the temporal evolution of the disease pertaining to epidemiological variables, clinical presentation and mortality. We present updated epidemiological data from the population-based Danish cohort of patients with acromegaly (AcroDEN), along with meta-analyses of existing estimates from around the world.Based on this, we conclude that the incidence, prevalence and age at acromegaly diagnosis are all steadily increasing, but with considerable variation between studies. An increased number of incidental cases may contribute to the increase in incidence and age at diagnosis, respectively. The clinical features at presentation are trending toward a milder disease phenotype at diagnosis, and advances in therapeutic options have reduced the mortality of patients with acromegaly to a level similar to that of the general population. Moreover, the underlying cause of death has shifted from cardiovascular to malignant neoplastic diseases.
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Affiliation(s)
- Christian Rosendal
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
| | | | | | | | - Claus Larsen Feltoft
- Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Caroline Kistorp
- Department of Hormone and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- Aarhus KEA, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jakob Dal
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
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13
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Westgeest AC, Lambregts MMC, Ruffin F, Korn RE, Webster ME, Kair JL, Parsons JB, Maskarinec SA, Kaplan S, Dekkers OM, de Boer MGJ, Fowler VG, Thaden JT. Female Sex and Mortality in Patients with Staphylococcus aureus Bacteremia: A Systematic Review and Meta-analysis. JAMA Netw Open 2024; 7:e240473. [PMID: 38411961 PMCID: PMC10900971 DOI: 10.1001/jamanetworkopen.2024.0473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/08/2024] [Indexed: 02/28/2024] Open
Abstract
Importance Staphylococcus aureus is the leading cause of death due to bacterial bloodstream infection. Female sex has been identified as a risk factor for mortality in S aureus bacteremia (SAB) in some studies, but not in others. Objective To determine whether female sex is associated with increased mortality risk in SAB. Data Sources MEDLINE, Embase, and Web of Science were searched from inception to April 26, 2023. Study Selection Included studies met the following criteria: (1) randomized or observational studies evaluating adults with SAB, (2) included 200 or more patients, (3) reported mortality at or before 90 days following SAB, and (4) reported mortality stratified by sex. Studies on specific subpopulations (eg, dialysis, intensive care units, cancer patients) and studies that included patients with bacteremia by various microorganisms that did not report SAB-specific data were excluded. Data Extraction and Synthesis Data extraction and quality assessment were performed by 1 reviewer and verified by a second reviewer. Risk of bias and quality were assessed with the Newcastle-Ottawa Quality Assessment Scale. Mortality data were combined as odds ratios (ORs). Main Outcome and Measures Mortality at or before 90-day following SAB, stratified by sex. Results From 5339 studies retrieved, 89 were included (132 582 patients; 50 258 female [37.9%], 82 324 male [62.1%]). Unadjusted mortality data were available from 81 studies (109 828 patients) and showed increased mortality in female patients compared with male patients (pooled OR, 1.12; 95% CI, 1.06-1.18). Adjusted mortality data accounting for additional patient characteristics and treatment variables were available from 32 studies (95 469 patients) and revealed a similarly increased mortality risk in female relative to male patients (pooled adjusted OR, 1.18; 95% CI, 1.11-1.27). No evidence of publication bias was encountered. Conclusions and Relevance In this systematic review and meta-analysis, female patients with SAB had higher mortality risk than males in both unadjusted and adjusted analyses. Further research is needed to study the potential underlying mechanisms.
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Affiliation(s)
- Annette C. Westgeest
- Division of Infectious Diseases, Duke University, Durham, North Carolina
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Merel M. C. Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Felicia Ruffin
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Rachel E. Korn
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Maren E. Webster
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Jackson L. Kair
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Joshua B. Parsons
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | | | - Samantha Kaplan
- Medical Center Library and Archives, Duke University, Durham, North Carolina
| | - Olaf M. Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G. J. de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Vance G. Fowler
- Division of Infectious Diseases, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Joshua T. Thaden
- Division of Infectious Diseases, Duke University, Durham, North Carolina
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14
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Rademaker R, Kimura Y, de Riva Silva M, Beukers HC, Piers SRD, Wijnmaalen AP, Dekkers OM, Zeppenfeld K. Area-weighted unipolar voltage to predict heart failure outcomes in patients with ischaemic cardiomyopathy and ventricular tachycardia. Europace 2024; 26:euad346. [PMID: 38308809 PMCID: PMC10838146 DOI: 10.1093/europace/euad346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/15/2023] [Indexed: 02/05/2024] Open
Abstract
AIMS Patients with ischaemic cardiomyopathy (ICM) referred for catheter ablation of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodelling. Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV parameter reflecting global viable myocardium may predict prognosis. We evaluate if a newly proposed parameter, area-weighted unipolar voltage (awUV), can predict HF-related outcomes [HFO; HF death/left ventricular (LV) assist device/heart transplant] in ICM. METHODS AND RESULTS From endocardial voltage maps of consecutive patients with ICM referred for VT ablation, awUV was calculated by weighted interpolation of local UV. Associations between clinical and mapping parameters and HFO were evaluated and validated in a second cohort. The derivation cohort consisted of 90 patients [age 68 ±8 years; LV ejection fraction (LVEF) 35% interquartile range (IQR) (24-40)] and validation cohort of 60 patients [age 67 ± 9, LVEF 39% IQR (29-45)]. In the derivation cohort, during a median follow-up of 45 months [IQR (34-83)], 36 (43%) patients died and 23 (26%) had HFO. Patients with HFO had lower awUV [4.51 IQR (3.69-5.31) vs. 7.03 IQR (6.08-9.2), P < 0.001]. A reduction in awUV [optimal awUV (5.58) cut-off determined by receiver operating characteristics analysis] was a strong predictor of HFO (3-year HFO survival 97% vs. 57%). The cut-off value was confirmed in the validation cohort (2-year HFO-free survival 96% vs. 60%). CONCLUSION The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at high risk for HFO.
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Affiliation(s)
- Robert Rademaker
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Yoshi Kimura
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Marta de Riva Silva
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Hans C Beukers
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Sebastiaan R D Piers
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
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15
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Groenwold RHH, Dekkers OM. Dependent observations in clinical research. Eur J Endocrinol 2024; 190:E1-E3. [PMID: 38300746 DOI: 10.1093/ejendo/lvae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
For many statistical methods that are commonly used in medical research, it is assumed that observations are independent. However, when this assumption is violated, alternative methods may be needed. In this paper, we describe why an analysis that ignores the dependencies within the data may provide biased results and outline possible alternatives. This paper aims to create awareness among researchers, readers, and reviewers for this possible source of bias in medical research.
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Affiliation(s)
- Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
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16
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Leerling AT, Smit F, Spӓth Z, Cañete AN, de Geus-Oei LF, van de Burgt A, Dekkers OM, van der Bruggen W, Appelman-Dijkstra NM, Vriens D, Winter EM. 18F-Sodium fluoride PET-CT visualizes disease activity in chronic nonbacterial osteitis in adults. JBMR Plus 2024; 8:ziad007. [PMID: 38505528 PMCID: PMC10945721 DOI: 10.1093/jbmrpl/ziad007] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/21/2023] [Accepted: 01/26/2024] [Indexed: 03/21/2024] Open
Abstract
Chronic nonbacterial osteitis (CNO) is a rare disease spectrum, which lacks biomarkers for disease activity. Sodium fluoride-18 positron emission tomography/computed tomography ([18F]NaF-PET/CT) is a sensitive imaging tool for bone diseases and yields quantitative data on bone turnover. We evaluated the capacities of [18F]NaF-PET/CT to provide structural and functional assessment in adult CNO. A coss-sectional study was performed including 43 adult patients with CNO and 16 controls (patients referred for suspected, but not diagnosed with CNO) who underwent [18F]NaF-PET/CT at our expert clinic. Structural features were compared between patients and controls, and maximal standardized uptake values (SUVmax [g/mL]) were calculated for bone lesions, soft tissue/joint lesions, and reference bone. SUVmax was correlated with clinical disease activity in patients. Structural assessment revealed manubrial and costal sclerosis/hyperostosis and calcification of the costoclavicular ligament as typical features associated with CNO. SUVmax of CNO lesions was higher compared with in-patient reference bone (mean paired difference: 11.4; 95% CI: 9.4-13.5; p < .001) and controls (mean difference: 12.4; 95%CI: 9.1-15.8; p < .001). The highest SUVmax values were found in soft tissue and joint areas such as the costoclavicular ligament and manubriosternal joint, and these correlated with erythrocyte sedimentation rate in patients (correlation coefficient: 0.546; p < .002). Our data suggest that [18F]NaF-PET/CT is a promising imaging tool for adult CNO, allowing for detailed structural evaluation of its typical bone, soft-tissue, and joint features. At the same time, [18F]NaF-PET/CT yields quantitative bone remodeling data that represent the pathologically increased bone turnover and the process of new bone formation. Further studies should investigate the application of quantified [18F]NaF uptake as a novel biomarker for disease activity in CNO, and its utility to steer clinical decision making.
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Affiliation(s)
- Anne T Leerling
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Frits Smit
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, 2353 GA, The Netherlands
| | - Zita Spӓth
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Ana Navas Cañete
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Lioe-Fee de Geus-Oei
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Radiation Science and Technology, Delft University of Technology, Delft, 2628 CD, The Netherlands
| | - Alina van de Burgt
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, 2353 GA, The Netherlands
| | - Olaf M Dekkers
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Wouter van der Bruggen
- Department of Nuclear Medicine, Slingeland Hospital, Doetinchem, 7009 BL, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Dennis Vriens
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Elizabeth M Winter
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
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17
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Leerling AT, Andeweg EH, Faber J, Streefland TC, Dekkers OM, Appelman‐Dijkstra NM, Winter EM. Immunological Characterization of Chronic Nonbacterial Osteomyelitis (CNO) in Adults: A Cross-Sectional Exploratory Study. JBMR Plus 2023; 7:e10818. [PMID: 38130757 PMCID: PMC10731106 DOI: 10.1002/jbm4.10818] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/17/2023] [Accepted: 08/24/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is a rare disease spectrum affecting children and adults. Adult CNO may occur as isolated bone inflammation, or with a broad range of extraskeletal features. CNO pathophysiology, including the key drivers of inflammation, remains largely unknown. For pediatric CNO, a role for pro-inflammatory cytokine dysregulation has been proposed, but studies in adults are scarce. We therefore provide immunological characterization of adult CNO. Cross-sectional study in our referral center including adult CNO patients (n = 172) and healthy controls (n = 65). Inflammation parameters and systemic inflammatory based scores(SIBS, including neutrophil/lymphocyte ratio [NLR] and systemic immune inflammation index [SII]) were compared between groups. Cytokine expression was explored with electrochemiluminescent immunoassays in 33 patients, eight healthy controls and 21 osteoporosis patients. Routine inflammation markers were higher in patients than in controls, but generally remained within reference range. Systemic inflammation was more pronounced in patients with additional vertebral involvement as compared to those osteitis in the anterior chest wall alone, in patients with comorbid pustulosis palmoplantaris or psoriasis, and in patients with strongly rather than moderately increased lesional uptake on nuclear imaging. SII was elevated in CNO patients too, but NLR was not. Cytokine expression was generally nondifferential between patients and both control groups, and patients displayed low absolute concentrations of pro-inflammatory cytokines. In this adult CNO cohort, systemic inflammation was generally subtle, but more pronounced in patients with vertebral lesions, associated skin disease, and strongly increased uptake on nuclear imaging. SII was increased in patients compared to healthy controls. Contrasting pediatric studies, we found no increased expression of the pro-inflammatory cytokines that have been proposed to drive the inflammatory cascade, like interleukin-6, -8, and -17 (IL-6, IL-8, and IL-17), and tumor necrosis α (TNF-α). Further studies are needed to evaluate the use of SII in diagnosis and monitoring of CNO, and elucidate the role of cytokine dysregulation in adult disease. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Anne T. Leerling
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Bone QualityLeiden University Medical CenterLeidenThe Netherlands
| | - Elisabeth H. Andeweg
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Bone QualityLeiden University Medical CenterLeidenThe Netherlands
| | - Juliette Faber
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Bone QualityLeiden University Medical CenterLeidenThe Netherlands
| | - Trea C.M. Streefland
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
| | - Olaf M. Dekkers
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Natasha M. Appelman‐Dijkstra
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Bone QualityLeiden University Medical CenterLeidenThe Netherlands
| | - Elizabeth M. Winter
- Department of Internal Medicine, Division of EndocrinologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Bone QualityLeiden University Medical CenterLeidenThe Netherlands
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18
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Ali SR, Bryce J, Priego-Zurita AL, Cherenko M, Smythe C, de Rooij TM, Cools M, Danne T, Katugampola H, Dekkers OM, Hiort O, Linglart A, Netchine I, Nordenstrom A, Attila P, Persani L, Reisch N, Smyth A, Sumnik Z, Taruscio D, Visser WE, Pereira AM, Appelman-Dijkstra NM, Ahmed SF. Electronic reporting of rare endocrine conditions within a clinical network: results from the EuRRECa project. Endocr Connect 2023; 12:e230434. [PMID: 37902973 PMCID: PMC10692689 DOI: 10.1530/ec-23-0434] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 11/01/2023]
Abstract
Objective The European Registries for Rare Endocrine Conditions (EuRRECa, eurreb.eu) includes an e-reporting registry (e-REC) used to perform surveillance of conditions within the European Reference Network (ERN) for rare endocrine conditions (Endo-ERN). The aim of this study was to report the experience of e-REC over the 3.5 years since its launch in 2018. Methods Electronic reporting capturing new encounters of Endo-ERN conditions was performed monthly through a bespoke platform by clinicians registered to participate in e-REC from July 2018 to December 2021. Results The number of centres reporting on e-REC increased to a total of 61 centres from 22 countries. A median of 29 (range 11, 45) paediatric and 32 (14, 51) adult centres had reported cases monthly. A total of 9715 and 4243 new cases were reported in adults (age ≥18 years) and children, respectively. In children, sex development conditions comprised 40% of all reported conditions and transgender cases were most frequently reported, comprising 58% of sex development conditions. The median number of sex development cases reported per centre per month was 0.6 (0, 38). Amongst adults, pituitary conditions comprised 44% of reported conditions and pituitary adenomas (69% of cases) were most commonly reported. The median number of pituitary cases reported per centre per month was 4 (0.4, 33). Conclusions e-REC has gained increasing acceptability over the last 3.5 years for capturing brief information on new encounters of rare conditions and shows wide variations in the rate of presentation of these conditions to centres within a reference network. Significance statement Endocrinology includes a very wide range of rare conditions and their occurrence is often difficult to measure. By using an electronic platform that allowed monthly reporting of new clinical encounters of several rare endocrine conditions within a defined network that consisted of several reference centres in Europe, the EuRRECa project shows that a programme of e-surveillance is feasible and acceptable. The data that have been collected by the e-reporting of rare endocrine conditions (e-REC) can allow the continuous monitoring of rare conditions and may be used for clinical benchmarking, designing new studies or recruiting to clinical trials.
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Affiliation(s)
- S R Ali
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - J Bryce
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - A L Priego-Zurita
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - M Cherenko
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - C Smythe
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - T M de Rooij
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - M Cools
- Department of Internal Medicine and Paediatrics, Ghent University, Belgium
- Department of Paediatric Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - T Danne
- Diabetes Center AUF DER BULT, Hannover, Germany
| | | | - O M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medicine & Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - O Hiort
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics and Adolescent Medicine, University of Lübeck, Lübeck, Germany
| | - A Linglart
- AP-HP, Université Paris Saclay, INSERM, Bicêtre Paris Saclay Hospital, le Kremlin Bicêtre, France
| | - I Netchine
- Sorbonne Université, Inserm, Centre de recherche Sainte Antoine, APHP, Hôpital des Enfants Armand Trousseau, Paris, France
| | - A Nordenstrom
- Pediatric Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P Attila
- Clinical Genetics and Endocrinology Laboratory, Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | - L Persani
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - N Reisch
- Endokrinologie, Medizinische Klinik Innenstadt und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - A Smyth
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Z Sumnik
- Department of Pediatrics, Motol University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - D Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - W E Visser
- Erasmus Medical Centre, Department of Internal Medicine, Academic Centre for Thyroid Diseases, Rotterdam, the Netherlands
| | - A M Pereira
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands
| | - N M Appelman-Dijkstra
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - S F Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
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19
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Groenwold RHH, Dekkers OM. Look left, look right: censoring in clinical research. Eur J Endocrinol 2023; 189:E1-E3. [PMID: 37956460 DOI: 10.1093/ejendo/lvad152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023]
Abstract
In this methodology editorial, the problem of censored survival (or time-to-event) data in clinical research is discussed. In case of censored observations, part of the observation time for some participants in a study is unobserved, which means that measures such as an average survival time cannot be calculated. Instead, censored survival time should explicitly be accounted for in the analysis of a study, for example using the Kaplan-Meier method. Implications of censoring and how to deal with it in the analysis of a study or when reading a research paper are discussed.
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Affiliation(s)
- Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
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20
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Pelsma ICM, Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J, Marina L, Lorenz K, Bancos I, Arlt W, Dekkers OM. Comorbidities in mild autonomous cortisol secretion and the effect of treatment: systematic review and meta-analysis. Eur J Endocrinol 2023; 189:S88-S101. [PMID: 37801655 DOI: 10.1093/ejendo/lvad134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/12/2023] [Accepted: 09/04/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To assess (1) comorbidities associated with and (2) treatment strategies for patients with adrenal incidentalomas and mild autonomous cortisol secretion (MACS; > 1.8 µg/dL (>50 nmol/L) cortisol level cut-off following the 1 mg dexamethasone suppression test). DESIGN Systematic review and meta-analysis. METHODS Seven databases were searched up to July 14, 2022. Eligible studies were (randomized) trials, cohort studies, and cross-sectional studies assessing comorbidities potentially attributable to cortisol excess or mortality in patients with adrenal incidentaloma with or without MACS or the effects of conservative or surgical management of MACS. Random-effects meta-analysis was performed to estimate pooled proportions (with 95% CIs). RESULTS In 30 cross-sectional and 16 cohort studies (n = 17 156 patients in total), patients with MACS had a higher prevalence of diabetes (relative risk [RR] 1.44 [1.23-1.69]), hypertension (RR = 1.24 [1.16-1.32]), and dyslipidemia (RR = 1.23 [1.13-1.34]). All-cause mortality (adjusted for confounders) in patients with MACS, assessed in 4 studies (n = 5921), was increased (hazard ratio [HR] = 1.54 [1.27-1.81]). Nine observational studies (n = 856) and 2 randomized trials (n = 107) suggest an improvement in glucometabolic control (RR = 7.99 [2.95-21.90]), hypertension (RR = 8.75 [3.99-19.18]), and dyslipidemia (RR = 3.24 [1.19-8.82]) following adrenalectomy. CONCLUSIONS The present systematic review and meta-analysis highlight the relevance of MACS, since both cardiometabolic morbidities and mortality appeared to have increased in patients with MACS compared to patients with non-functioning incidentalomas. However, due to heterogeneous definitions, various outcomes, selective reporting, and missing data, the reported pooled estimates need to be interpreted with caution. The small number of patients in randomized trials prevents any strong conclusion on the causality between MACS and these comorbidities.
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Affiliation(s)
- Iris C M Pelsma
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Oberdürrbacherstrasse 6, Würzburg 97080, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Josef-Schneider-Straße 2, Würzburg 97080, Germany
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Ipsilantou 45-47, Athens 106 76, Greece
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Hospital University of Turin, Regione Gonzole, Orbassano-Torrino 10 10043, Italy
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University and CHU of Bordeaux, Pl. Amélie Raba Léon, Bordeaux 33000, France
| | - Anju Sahdev
- Department of Imaging, St Bartholomew's Hospital, Barts Health, London EC1A 7BE, United Kingdom
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield S10 2RX, United Kingdom
- Endocrine Services, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, United Kingdom
| | - Ljiljana Marina
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 8, Belgrade 11000, Serbia
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale) 06108, Germany
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, MN 55905, United States
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
| | - Olaf M Dekkers
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Allé 43-45, Aarhus N 8200, Denmark
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21
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Vollaard AM, Slok ENE, van Dijkman PRM, Dekkers OM, Groeneveld GH. [Influenza vaccination as secondary prevention for cardiovascular disease]. Ned Tijdschr Geneeskd 2023; 167:D7829. [PMID: 37823884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Influenza infection increases the risk of cardiovascular complications and mortality in patients with heart disease. In patients with coronary artery disease influenza vaccination has been shown to reduce cardiovascular mortality, but high-quality evidence was missing. New trial data from a RCT in patients shortly after myocardial infarction has confirmed the significant reduction of the risk of major adverse cardiovascular events (MACE) and cardiovascular death after influenza vaccination. Also in patients with heart failure the first published RCT in heart failure shows a clinical benefit of influenza vaccination versus placebo during the influenza season, confirming preceding observational studies. Meta-analyses from the study data estimate that after influenza vaccination a risk reduction of MACE of at least 25% is possible in patients with heart disease. The current underutilization of influenza vaccines in heart patients should be addressed because influenza vaccination has proven to be an effective and safe instrument for secondary prevention.
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Affiliation(s)
- Albert M Vollaard
- RIVM, Centrum Infectieziektebestrijding, Bilthoven
- Contact: Albert M. Vollaard
| | | | | | - Olaf M Dekkers
- Leids Universitair Medisch Centrum, afd. Klinische epidemiologie en Endocrinologie, Leiden
| | - Geert H Groeneveld
- Leids Universitair Medisch Centrum, afd. Interne geneeskunde en Infectieziekten, Leiden
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22
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Ghariq M, van den Hout WB, Dekkers OM, Bootsma M, de Groot B, Groothuis JGJ, Harms MPM, Hemels MEW, Kaal ECA, Koomen EM, de Lange FJ, Peeters SYG, van Rossum IA, Rutten JHW, van Zwet EW, van Dijk JG, Thijs RD. Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study). BMC Med 2023; 21:365. [PMID: 37743496 PMCID: PMC10518933 DOI: 10.1186/s12916-023-03056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs. METHODS A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis. RESULTS We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782). CONCLUSIONS ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs. TRIAL REGISTRATION Netherlands Trial Register, NTR6268.
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Affiliation(s)
- M Ghariq
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G J Groothuis
- Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
| | - M P M Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E M Koomen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - F J de Lange
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - S Y G Peeters
- Department of Emergency Medicine, Flevo Hospital, Almere, The Netherlands
| | - I A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - J H W Rutten
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - R D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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23
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Dekkers OM, Wilmsen N, Geerlings W. [Challenges for evaluating complex interventions: The example of lifestyle]. Ned Tijdschr Geneeskd 2023; 167:D7418. [PMID: 37609938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Lifestyle interventions potentially contribute to the prevention and treatment of a number of common chronic diseases, such as type 2 diabetes and obesity. Nobody questions the importance of a healthy lifestyle, but at the same time it is clear that the effectiveness of lifestyle interventions has often not been investigated in a randomized controlled study, whereas the randomized clinical trial (RCT) is the golden standard in clinical drug research. In this article we discuss the methodological (im)possibilities of using RCTs in evaluating the effects of lifestyle interventions. We also explore the value of other research methods, especially carefully designed non-randomized clinical trials. Under the right conditions, non-randomized 'real world' research can provide valid evidence for the effectiveness and safety of lifestyle interventions.
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Affiliation(s)
- Olaf M Dekkers
- Leids Universitair Medisch Centrum, afd. Interne Geneeskunde
- Contact: Olaf M. Dekkers
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Groenwold RHH, Dekkers OM. Subgroup analyses in clinical research: too tempting? Eur J Endocrinol 2023:lvad089. [PMID: 37527541 DOI: 10.1093/ejendo/lvad089] [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] [Received: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 08/03/2023]
Abstract
In many biomedical studies, subgroup analyses are performed to identify subgroups of patients in whom a treatment is most effective, or a risk factor has the largest effect. While both are referred to as subgroup analysis, it is important to distinguish between estimation of effects within subgroups and comparison of effects across subgroups. Both are discussed and we outline the implications regarding sample size and statistical methods for estimation of effects. Also, the risk of false-positive findings - which potentially increases with subgroup analysis - is discussed, as well as the distinction between effect modification and interaction.
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Affiliation(s)
- Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
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Leerling AT, Clunie G, Koutrouba E, Dekkers OM, Appelman-Dijkstra NM, Winter EM. Diagnostic and therapeutic practices in adult chronic nonbacterial osteomyelitis (CNO). Orphanet J Rare Dis 2023; 18:206. [PMID: 37480122 PMCID: PMC10362746 DOI: 10.1186/s13023-023-02831-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Chronic nonbacterial osteomyelitis (CNO) is a rare, and impactful auto-inflammatory bone disease occurring in children and adults. Clinical care for CNO is challenging, as the condition lacks validated classification criteria and evidence-based therapies. This study aimed to map the current diagnostic and therapeutic practices for CNO in adults, as a first step towards a standardized disease definition and future consensus treatment plans. METHODS A primary survey was spread among global rheumatological/bone networks and 57 experts as identified from literature (May 2022), covering terminology, diagnostic tools (clinical, radiological, biochemical) and treatment steps. A secondary survey (sent to primary survey responders in August 2022) further queried key diagnostic features, treatment motivations, disease activity and treatment response monitoring. RESULTS 36 and 23 physicians completed the primary and secondary survey respectively. Diagnosis was mainly based on individual physician assessment, in which the combination of chronic relapsing-remitting bone pain with radiologically-proven osteitis/osteomyelitis, sclerosis, hyperostosis and increased isotope uptake on bone scintigraphy were reported indicative of CNO. Physicians appeared more likely to refer to the condition as synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in the presence of joint and skin pathology. MRI was most frequently performed, and the preferred diagnostic test for 47%. X-rays were second-most frequently used, although considered least informative of all available tools. Typical imaging features reported were hyperostosis, osteitis, osteosclerosis, bone marrow edema, while degeneration, soft tissue calcification, and ankylosis were not regarded characteristic. Inflammation markers and bone markers were generally regarded unhelpful for diagnostic and monitoring purposes and physicians infrequently performed bone biopsies. Management strategies diverged, including indications for treatment, response monitoring and declaration of remission. Step-1 treatment consisted of non-steroidal anti-inflammatory drugs/COX-2 inhibitors (83%). Common step 2-3 treatments were pamidronate, methotrexate, and TNF-a-inhibition (anti-TNFα), the latter two regarded especially convenient to co-target extra-skeletal inflammation in SAPHO syndrome. Overall pamidronate and anti-TNFα and were considered the most effective treatments. CONCLUSIONS Following from our survey data, adult CNO is a broad and insufficiently characterized disease spectrum, including extra-osseous features. MRI is the favoured imaging diagnostic, and management strategies vary significantly. Overall, pamidronate and anti-TNFα are regarded most successful. The results lay out current practices for adult CNO, which may serve as backbone for a future consensus clinical guideline.
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Affiliation(s)
- A T Leerling
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - G Clunie
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Koutrouba
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - O M Dekkers
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - N M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - E M Winter
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands.
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands.
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Burman P, Casar-Borota O, Perez-Rivas LG, Dekkers OM. Aggressive Pituitary Tumors and Pituitary Carcinomas: From Pathology to Treatment. J Clin Endocrinol Metab 2023; 108:1585-1601. [PMID: 36856733 PMCID: PMC10271233 DOI: 10.1210/clinem/dgad098] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
Aggressive pituitary tumors (APTs) and pituitary carcinomas (PCs) are heterogeneous with regard to clinical presentation, proliferative markers, clinical course, and response to therapy. Half of them show an aggressive course only many years after the first apparently benign presentation. APTs and PCs share several properties, but a Ki67 index greater than or equal to 10% and extensive p53 expression are more prevalent in PCs. Mutations in TP53 and ATRX are the most common genetic alterations; their detection might be of value for early identification of aggressiveness. Treatment requires a multimodal approach including surgery, radiotherapy, and drugs. Temozolomide is the recommended first-line chemotherapy, with response rates of about 40%. Immune checkpoint inhibitors have emerged as second-line treatment in PCs, with currently no evidence for a superior effect of dual therapy compared to monotherapy with PD-1 blockers. Bevacizumab has resulted in partial response (PR) in few patients; tyrosine kinase inhibitors and everolimus have generally not been useful. The effect of peptide receptor radionuclide therapy is limited as well. Management of APT/PC is challenging and should be discussed within an expert team with consideration of clinical and pathological findings, age, and general condition of the patient. Considering that APT/PCs are rare, new therapies should preferably be evaluated in shared standardized protocols. Prognostic and predictive markers to guide treatment decisions are needed and are the scope of ongoing research.
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Affiliation(s)
- Pia Burman
- Department of Endocrinology, Skåne University Hospital, Lund
University, 205 02 Malmö, Sweden
| | - Olivera Casar-Borota
- Department of Immunology, Genetics, and Pathology; Uppsala
University, 751 85 Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University
Hospital, 751 85 Uppsala, Sweden
| | - Luis Gustavo Perez-Rivas
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München,
Ludwig-Maximilians-Universität München, 80804
Munich, Germany
| | - Olaf M Dekkers
- Department of Internal Medicine (Section of Endocrinology & Clinical
Epidemiology), Leiden University Medical Centre, 2333 ZA
Leiden, The Netherlands
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Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J, Pelsma I, Marina L, Lorenz K, Bancos I, Arlt W, Dekkers OM. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2023:lvad066. [PMID: 37318239 DOI: 10.1093/ejendo/lvad066] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
Adrenal incidentalomas are adrenal masses detected on imaging performed for reasons other than suspected adrenal disease. In most cases, adrenal incidentalomas are non-functioning adrenocortical adenomas, but may also require therapeutic intervention including that for adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastases. Here, we provide a revision of the first international, interdisciplinary guidelines on incidentalomas. We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and updated systematic reviews on four predefined clinical questions crucial for the management of incidentalomas: A) How to assess risk of malignancy? ; B) How to define and manage mild autonomous cortisol secretion? ; C) Who should have surgical treatment and how should it be performed? ; D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? Selected Recommendations: 1) Each adrenal mass requires dedicated adrenal imaging. Recent advances now allow discrimination between risk categories: Homogeneous lesions with HU ≤ 10 on unenhanced CT are benign and do not require any additional imaging independent of size. All other patients should be discussed in a multidisciplinary expert meeting, but only lesions >4 cm that are inhomogeneous or have HU >20 have sufficiently high risk of malignancy that surgery will be the usual management of choice. 2) Every patient needs a thorough clinical and endocrine work-up to exclude hormone excess including the measurement of plasma or urinary metanephrines and a 1-mg overnight dexamethasone suppression test (applying a cutoff value of serum cortisol ≤50 nmol/l (≤1.8 µg/dl)). Recent studies have provided evidence that most patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post dexamethasone >50 nmol/l (>1.8 µg/dl) harbor increased risk of morbidity and mortality. For this condition, we propose the term 'mild autonomous cortisol secretion' (MACS). 3) All patients with MACS should be screened for potential cortisol-related comorbidities that are potentially attributably to cortisol (e.g. hypertension and type 2 diabetes mellitus), to ensure these are appropriately treated. 4) In patients with MACS who also have relevant comorbidities surgical treatment should be considered in an individualized approach. 5) The appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. 6) Surgery is not usually indicated in patients with an asymptomatic, non-functioning unilateral adrenal mass and obvious benign features on imaging studies. Furthermore, we offer recommendations for the follow-up of non-operated patients, management of patients with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses, and for young and elderly patients with adrenal incidentalomas. Finally, we suggest ten important research questions for the future.
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Affiliation(s)
- Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Antoine Tabarin
- Department of Endocrinology, diabetes and nutrition, University and CHU of Bordeaux, France
| | - Anju Sahdev
- Department of Imaging, St Bartholomew's Hospital, Barts Health, London, EC1A 7BE, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield, S10 2RX, UK
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, S10 2JF, UK
| | - Iris Pelsma
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ljiljana Marina
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Serbia
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, MN, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Choi J, Dekkers OM, le Cessie S. Tying research question and analytical strategy when variables are affected by medication use. Pharmacoepidemiol Drug Saf 2023; 32:661-670. [PMID: 36738180 DOI: 10.1002/pds.5599] [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] [Received: 10/12/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
Ill-defined research questions could be particularly problematic in an epidemiological setting where measurements fluctuate over time due to intercurrent events, such as medication use. When a research question fails to specify how medication use should be handled methodologically, arbitrary decisions may be made during the analysis phase, which likely leads to a mismatch between the intended question and the performed analysis. The mismatch can result in vastly different or meaningless interpretations of estimated effects. Thus, a research question such as "what is the effect of X on Y?" requires further elaboration, and it should consider whether and how medication use has affected the measurements of interest. In our study, we will discuss how well-defined questions can be formulated when medication use is involved in observational studies. We will distinguish between a situation where an exposure is affected by medication use and where the outcome of interest is affected by medication use. For each setting, we will give examples of different research questions that could be asked depending on how medication use is considered in the estimand and discuss methodological considerations under each question.
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Affiliation(s)
- Jungyeon Choi
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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Ravensberg AJ, Poortvliet RKE, Du Puy RS, Dekkers OM, Mooijaart SP, Gussekloo J. Effects of discontinuation of levothyroxine treatment in older adults: protocol for a self-controlled trial. BMJ Open 2023; 13:e070741. [PMID: 37185193 PMCID: PMC10151847 DOI: 10.1136/bmjopen-2022-070741] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Many older persons use the thyroid hormone levothyroxine which is often continued for life. Scientifically, there is much uncertainty whether simple continuation is the optimal approach. First, the physical need for levothyroxine can decrease with age thereby posing a higher risk of overtreatment and adverse effects. Second, large trials in subclinical hypothyroidism have shown no benefit for the use of levothyroxine. Interestingly, guidelines do not address re-evaluation of the indication. This self-controlled trial aims to determine the effects of discontinuation of levothyroxine treatment in older adults. METHODS AND ANALYSIS Participants are community-dwelling subjects aged ≥60 years using levothyroxine continuously at a stable dosage of ≤150 µg and a level of thyroid-stimulating hormone (TSH) <10 mU/L. After a control period of 12 weeks, levothyroxine treatment is discontinued gradually using a stepwise approach with regular monitoring of thyroid function guided by their GP. The primary outcome is the proportion of participants withdrawn from levothyroxine while maintaining a free T4 level within the reference range and a TSH level <10 mU/L, 52 weeks after the start of discontinuation. Secondary outcomes are compared with the control period (self-controlled) and include among others, the effects on thyroid-specific and general health-related quality of life. Furthermore, patients' attitudes towards deprescribing and regret regarding discontinuing levothyroxine treatment will be recorded. A total of 513 participants will be recruited to estimate the expected proportion of 50% with a 95% CI ranging from 45% to 55%. ETHICS AND DISSEMINATION Approval was obtained from the institutional Medical Ethics Committee. The Older People Advisory Board Health and Well-being has reviewed the research proposal and their comments were used for improvement. In line with the funding policies of the grant organisation funding this study, the study results will be proactively disseminated to the general public and key public health stakeholders. TRIAL REGISTRATION NUMBER NL7978; NCT05821881.
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Affiliation(s)
- A Janneke Ravensberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- University Network for the Care Sector Zuid-Holland, Leiden University Medical Center, Leiden, Netherlands
| | - Robert S Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Olaf M Dekkers
- Endocrinology and Metabolic Disorders, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
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30
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Trouillas J, Burman P, Losa M, McCormack A, Petersenn S, Popovic V, Theodoropoulou M, Dekkers OM, Raverot G. Initial pathology in aggressive pituitary tumours and carcinomas: 2b or not 2b?-that is the question. Eur J Endocrinol 2023; 188:C5-C8. [PMID: 36952293 DOI: 10.1093/ejendo/lvad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/27/2023] [Accepted: 03/22/2023] [Indexed: 03/24/2023]
Abstract
Abstract
From a cohort of 171 patients comprising 121 aggressive pituitary tumours (APT) and 50 pituitary carcinomas (PC), the clinicopathological or five-tiered classification based on tumour invasion and proliferation evaluated by at least 2 proliferative markers over the cut-offs (Ki-67 ≥3% or ≥10%, p53 positive or expressed in %, mitotic count >2%), could be applied on 43 tumours: 20 PC and 23 APT. At the initial surgery, 29/43 tumours (67.4%) were grade 2b (invasive and proliferative) of which 44.8% developed metastases during follow-up (PC, grade 3). Out of these 29 tumours, 55.1% had a Ki-67 ≥10%, and were classified grade 2b* (invasive and highly proliferative). There was one tumour grade 1b* (non-invasive and highly proliferative) which metastazed. Out of the 43 tumours, 30.2 % were grade 2a (invasive and non-proliferative). The sensitivity and the specificity of grade 2b for the diagnosis of APT at the initial surgery, were 68% and 90% respectively. The comparison of the high percentage (67.4%) of grade 2b tumours in this selected cohort of APT/PC with the low percentage (8.8%) in a surgical cohort of unselected tumours shows that the initial pathological diagnosis of grade 2b tumour may be considered, in the clinic, as representing a diagnosis of APT. In addition, a significant subgroup of tumours, which will develop metastases supports the proposal that an aggressive grade 2b tumour is “a tumour with malignant potential” or “a malignant tumour without metastases”. So, the clinician may take into account the pathological diagnosis, at the initial surgery, to propose a strict follow-up and to consider earlier use of radiotherapy and/or of temozolomide in the presence of tumours with aggressive behaviour.
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Affiliation(s)
- Jacqueline Trouillas
- Faculty of medicine Lyon-Est, University Claude Bernard Lyon 1, Lyon 69372, France
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, Malmö, Lund University, Malmö 214 28, Sweden
| | - Marco Losa
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan 20132, Italy
| | - Ann McCormack
- Department of Endocrinology, St. Vincent's Hospital, Sydney 2010, Australia
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Erik-Blumenfeld-Platz 27a, Hamburg 22587, Germany
| | - Vera Popovic
- School of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich 2333, Germany
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leids Universitair Medisch Centrum Centrum voor Humane en Klinische Genetica, Leiden 2300 RC, Netherlands
| | - Gerald Raverot
- Faculty of medicine Lyon-Est, University Claude Bernard Lyon 1, Lyon 69372, France
- Federation d'Endocrinologie, Hospices civils de Lyon, Bron 69677, France
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Falch CM, Olarescu NC, Bollerslev J, Dekkers OM, Heck A. Trends in incidence and mortality risk for acromegaly in Norway: a cohort study. Endocrine 2023; 80:152-159. [PMID: 36525222 PMCID: PMC10060282 DOI: 10.1007/s12020-022-03275-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Recent data have shown a decreasing overall mortality in acromegaly over the last decades. However, cancer incidence and cancer-related mortality still appear to be increased. Our aim was to obtain updated epidemiological data from Norway in a clinically well-defined cohort with complete register-based follow-up. METHODS Patients diagnosed with acromegaly from South-Eastern Norway between 1999-2019 (n = 262) and age and sex matched population controls (1:100) were included (n = 26,200). Mortality and cancer data were obtained from the Norwegian Cause of Death and Cancer Registry. Mortality and cancer incidence were compared by Kaplan-Meier analyses and Cox regression; we report hazard ratios (HRs) with 95% confidence intervals (95% CI). RESULTS Median age at diagnosis was 48.0 years (interquartile range (IQR): 37.6-58.0). Mean annual acromegaly incidence rate was 4.7 (95% CI 4.2-5.3) cases/106 person-years, and the point prevalence (2019) was 83 (95% CI 72.6-93.5) cases/106 persons. Overall mortality was not increased in acromegaly, HR 0.8 (95% CI 0.5-1.4), cancer-specific and cardiovascular-specific mortality was also not increased (HR: 0.7 (95% CI 0.3-1.8) and 0.8 (95% CI: 0.3-2.5) respectively). The HR for all cancers was 1.45 (1.0-2.1; p = 0.052). CONCLUSION In this large cohort study, covering the period 1999-2019, patients were treated with individualized multimodal management. Mortality was not increased compared to the general population and comparable with recent registry studies from the Nordic countries and Europe. Overall cancer risk was slightly, but not significantly increased in the patients.
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Affiliation(s)
- Camilla M Falch
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Nicoleta C Olarescu
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ansgar Heck
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Solmunde E, Falstie-Jensen AM, Lorenzen EL, Ewertz M, Reinertsen KV, Dekkers OM, Cronin-Fenton DP. Breast cancer, breast cancer-directed radiation therapy and risk of hypothyroidism: A systematic review and meta-analysis. Breast 2023; 68:216-224. [PMID: 36868138 PMCID: PMC9996441 DOI: 10.1016/j.breast.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 02/21/2023] Open
Abstract
OBJECTIVE Breast cancer and breast cancer-directed radiation therapy (RT) may increase the risk of late effects, such as hypothyroidism. We conducted a systematic review and meta-analysis to investigate the association between breast cancer, RT, and risk of hypothyroidism in breast cancer survivors. METHODS Through February 2022, we searched PubMed, EMBASE, and references of relevant articles, to identify papers on breast cancer and breast cancer-directed RT and subsequent risk of hypothyroidism. Articles were screened by title and abstract and reviewed for eligibility. We used a pre-formed data extraction sheet and identified key design elements that could potentially introduce bias. The main outcome was the confounder-adjusted relative risk (RR) of hypothyroidism in breast cancer survivors versus women without breast cancer, and in breast cancer survivors according to the receipt of RT to the supraclavicular lymph nodes. We used a random-effects model to calculate pooled RRs and associated 95% confidence intervals (95% CI). RESULTS From 951 papers screened by title and abstract, 34 full-text papers were reviewed for eligibility. We included 20 studies published between 1985 and 2021-19 were cohort studies. Compared with women without breast cancer, the pooled RR of hypothyroidism in breast cancer survivors was 1.48 (95% CI: 1.17, 1.87), with highest risk associated with RT to the supraclavicular region (RR = 1.69, 95% CI: 1.16, 2.46). The most important limitations of the studies were small sample size yielding estimates with low precision, and lack of data on potential confounders. CONCLUSION Breast cancer and radiation therapy to the supraclavicular lymph nodes is associated with an increased risk of hypothyroidism.
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Affiliation(s)
- Elisabeth Solmunde
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
| | - Anne Mette Falstie-Jensen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
| | - Ebbe L Lorenzen
- Department of Oncology, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Denmark
| | - Marianne Ewertz
- Department of Clinical Research, University of Southern Denmark, Denmark
| | - Kristin V Reinertsen
- National Advisory Unit on Late Effects After Cancer Treatment, Department of Oncology, Oslo University Hospital, Norwegian Radium Hospital, Norway
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark; Department of Epidemiology, Leiden University Medical Center, Netherlands
| | - Deirdre P Cronin-Fenton
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark.
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Dekkers OM, de Boer MGJ, Rosendaal FR. [What does excess mortality tell us?]. Ned Tijdschr Geneeskd 2023; 166. [PMID: 36928632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Excess mortality due to covid-19 is estimatedas actual mortality minus expected mortality in the covid-19 period. Excess mortality in 2020-2021 in the Netherlands is estimated to be 30,000 persons. Excess mortality should be divided in mortality as consequences of covid-19 infections (direct effects) and mortality due indirect effects of the pandemic. As excess mortality assesses mortality under one single scenario (the actual scenario including its specific measures), it cannot directly be used to know what the number of deaths would have been under different scenarios. In line, it cannot be used to determine whether actual measures in the covid-19 pandemic were optimal (or not). And obviously, excess mortality only assesses the impact on mortality, not the impact on other relevant health-related, sociological or economical areas.
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Affiliation(s)
- Olaf M Dekkers
- LUMC, afd. Klinische Epidemiologie(tevens: LUMC, afd. Endocrinologie, Leiden)
- Contact: Olaf M. Dekkers
| | - Mark G J de Boer
- LUMC, afd. Klinische Epidemiologie(tevens: LUMC, afd. Infectieziekten, Leiden)
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Dekkers OM, de Boer MGJ, Rosendaal FR. [What does excess mortality tell us?]. Ned Tijdschr Geneeskd 2023; 167. [PMID: 36943146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Excess mortality due to covid-19 is estimatedas actual mortality minus expected mortality in the covid-19 period. Excess mortality in 2020-2021 in the Netherlands is estimated to be 30,000 persons. Excess mortality should be divided in mortality as consequences of covid-19 infections (direct effects) and mortality due indirect effects of the pandemic. As excess mortality assesses mortality under one single scenario (the actual scenario including its specific measures), it cannot directly be used to know what the number of deaths would have been under different scenarios. In line, it cannot be used to determine whether actual measures in the covid-19 pandemic were optimal (or not). And obviously, excess mortality only assesses the impact on mortality, not the impact on other relevant health-related, sociological or economical areas.
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Affiliation(s)
- Olaf M Dekkers
- LUMC, afd. Klinische Epidemiologie(tevens: LUMC, afd. Endocrinologie, Leiden)
- Contact: Olaf M. Dekkers
| | - Mark G J de Boer
- LUMC, afd. Klinische Epidemiologie(tevens: LUMC, afd. Infectieziekten, Leiden)
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Mooijaart SP, Dekkers OM, Van den Bos F. [Vitamin D supplementation for all older people with COVID-19?]. Ned Tijdschr Geneeskd 2023; 167. [PMID: 36928421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Vitamin D supplementation has been suggested for many diseases and symptoms that are frequent in older people: loss of bone mineral density, falls, loss of muscle mass, infections (including COVID-19) and mortality. In observational studies, vitamin D concentration has been associated with many poor outcomes, but in most Randomized Controlled Trials, there is no beneficial effect of vitamin D supplementation on these outcomes, except for bone mineral density. An alternative explanation of the observed association may be 'confounding': older people with poor mobility have lower vitamin D, and irrespective of that also have poor outcomes. The recent COVIT-TRIAL seems to suggest there is benefit of high dose vitamin D supplementation compared to low dose on mortality in older people with COVID-19, but on closer methodological look this conclusion does not hold. Clinical guidelines rightly do not advise vitamin D supplementation for a whole range of diseases, including COVID-19.
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Affiliation(s)
- Simon P Mooijaart
- Leids Universitair Medisch Centrum, Leiden, hoofdafd. Interne Geneeskunde, sub-afd. Ouderengeneeskunde
- Contact: Simon P. Mooijaart
| | - Olaf M Dekkers
- Leids Universitair Medisch Centrum, Leiden, hoofdafd. Interne Geneeskunde, sub-afd. Endocrinologie
| | - Frederiek Van den Bos
- Leids Universitair Medisch Centrum, Leiden, hoofdafd. Interne Geneeskunde, sub-afd. Ouderengeneeskunde
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van der Kooij MK, Joosse A, Suijkerbuijk KPM, Aarts MJB, van den Berkmortel FWPJ, Blank CU, Boers-Sonderen MJ, van den Eertwegh AJM, de Groot JWB, Haanen JBAG, Hospers GAP, Piersma D, van Rijn RS, van der Veldt AAM, Vreugdenhil G, Westgeest HM, Wouters MWJM, Dekkers OM, Kapiteijn E. Failure to validate existing clinical prediction scale for response to PD-1 monotherapy in advanced melanoma in national cohort study. Br J Cancer 2023; 128:707-710. [PMID: 36564561 PMCID: PMC9977837 DOI: 10.1038/s41416-022-02088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 11/04/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Monique K van der Kooij
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, PO box 9600, 2300 RC, Leiden, The Netherlands
| | - Arjen Joosse
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3000 CA, Rotterdam, The Netherlands
| | - Karijn P M Suijkerbuijk
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maureen J B Aarts
- Department of Medical Oncology, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ, Maastricht, The Netherlands
| | | | - Christian U Blank
- Department of Medical Oncology, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marye J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, The Netherlands
| | - Alfonsus J M van den Eertwegh
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands
| | | | - John B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Djura Piersma
- Department of Medical Oncology, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - Rozemarijn S van Rijn
- Department of Medical Oncology, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Astrid A M van der Veldt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3000 CA, Rotterdam, The Netherlands
| | - Gerard Vreugdenhil
- Department of Medical Oncology, Maxima Medical Center, de Run 4600, 5500 MB, Veldhoven, The Netherlands
| | - Hans M Westgeest
- Department of Medical Oncology, Amphia Ziekenhuis, Langendijk 175, 4819 EV, Breda, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, PO box 9600, 2300 RC, Leiden, The Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, PO box 9600, 2300 RC, Leiden, The Netherlands.
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Leerling AT, Dekkers OM, Appelman-Dijkstra NM, Winter EM. Clinical and therapeutic diversity in adult chronic nonbacterial osteomyelitis (CNO) of the sternocostoclavicular region: a meta-analysis. Rheumatology (Oxford) 2023; 62:512-522. [PMID: 35961032 PMCID: PMC9891421 DOI: 10.1093/rheumatology/keac443] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Chronic nonbacterial osteomyelitis (CNO) is a rare inflammatory bone disease. The distinct CNO subtype that affects the anterior chest wall is descriptively named sternocostoclavicular hyperostosis (SCCH) and mainly occurs in adults. Literature on CNO/SCCH is scattered and lacks diagnostic and therapeutic consensus. METHODS Systematic review and meta-analysis aiming to characterize clinical presentation and therapeutic modalities applied in adult CNO/SCCH patients. Untransformed numerical data and double-arcsine transformed proportional data were pooled in a random effects model in R-4.0.5; proportions were reported with 95% CI. RESULTS Forty studies were included, containing data on 2030 and 642 patients for aim 1 and 2, respectively. A female predisposition (67%, 95% CI 60, 73) and major diagnostic delay (5 years 95% CI 3, 7) were noted. Clinical presentation included chest pain (89%, 95% CI 79, 96) and swelling (79%, 95% CI 62, 91). Patients suffered from pustulosis palmoplantaris (53%, 95% CI 37, 68), arthritis (24%, 95% CI 11, 39) and acne (8%, 95% CI 4, 13). Inflammatory markers were inconsistently elevated. Autoantibody and HLA-B27 prevalence was normal, and histopathology unspecific. Increased isotope uptake (99%, 95% CI 96, 100) was a consistent imaging finding. Among manifold treatments, pamidronate and biologicals yielded good response in 83%, 95% CI 60, 98 and 56%, 95% CI 26, 85, respectively. CONCLUSION CNO/SCCH literature proves heterogeneous regarding diagnostics and treatment. Timely diagnosis is challenging and mainly follows from increased isotope uptake on nuclear examination. Biopsies, autoantibodies and HLA status are non-contributory, and biochemical inflammation only variably detected. Based on reported data, bisphosphonates and biologicals seem reasonably effective, but due to limitations in design and heterogeneity between studies the precise magnitude of their effect is uncertain. Fundamentally, international consensus seems imperative to advance clinical care for CNO/SCCH.
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Affiliation(s)
- Anne T Leerling
- Department of Internal Medicine, Division of Endocrinology.,Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Internal Medicine, Division of Endocrinology
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology.,Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Department of Internal Medicine, Division of Endocrinology.,Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
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Groenwold RHH, Dekkers OM. Is it a risk factor, a predictor, or even both? The multiple faces of multivariable regression analysis. Eur J Endocrinol 2023; 188:6990869. [PMID: 36651166 DOI: 10.1093/ejendo/lvac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/19/2023]
Abstract
The medical research literature is abundant with regression analyses that include multiple covariates, so-called multivariable regression models. Despite their common application, the interpretation of their results is not always clear or claimed interpretations are not justified. To outline the distinctions between different interpretations, we describe several possible research objectives for which a multivariable regression analysis might be an appropriate way of analyzing the data. In addition, we describe caveats in the interpretation of results of multivariable regression analysis.
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Affiliation(s)
- Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
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Kimura Y, de Riva M, Ebert M, Glashan C, Wijnmaalen AP, Piers SR, Dekkers OM, Trines SA, Zeppenfeld K. Pleomorphic Ventricular Tachycardia in Dilated Cardiomyopathy Predicts Ventricular Tachycardia Recurrence After Ablation Independent From Cardiac Function: Comparison With Patients With Ischemic Heart Disease. Circ Arrhythm Electrophysiol 2023; 16:e010826. [PMID: 36595629 DOI: 10.1161/circep.121.010826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND In dilated cardiomyopathy (DCM), outcome after catheter ablation of ventricular tachycardia (VT) is modest, compared with ischemic heart disease (IHD). Pleomorphic VT (PL-VT) has been associated with fibrotic remodeling and end-stage heart failure in IHD. The prognostic role of PL-VT in DCM is unknown. METHODS Consecutive IHD (2009-2016) or DCM (2008-2018) patients undergoing ablation for monomorphic VT were included. PL-VT was defined as ≥1 spontaneous change of the 12-lead VT-morphology during the same induced VT episode. Patients were followed for VT recurrence and mortality. RESULTS A total of 247 patients (86% men; 63±13 years; IHD n=152; DCM n=95) underwent ablation for monomorphic VT. PL-VT was observed in 22 and 29 patients with IHD and DCM, respectively (14% versus 31%, P=0.003). In IHD, PL-VT was associated with lower LVEF (28±9% versus 34±12%, P=0.02) and only observed in those with LVEF<40%. In contrast, in DCM, PL-VT was not related to LVEF and induced in 27% of patients with LVEF>40%. During a median follow-up of 30 months, 79 (32%) patients died (IHD 48; DCM 31; P=0.88) and 120 (49%) had VT recurrence (IHD 59; DCM 61; P<0.001). PL-VT was associated with mortality in IHD but not in DCM. In IHD, VT recurrence was independently associated with LVEF, number of induced VTs, and procedural noncomplete success. Of note, in DCM, PL-VT (HR, 2.62 [95% CI, 1.47-4.69]), pathogenic mutation (HR, 2.13 [95% CI, 1.16-3.91]), and anteroseptal VT substrate (HR, 1.75 [95% CI, 1.00-3.07]) independently predicted VT recurrence. CONCLUSIONS In IHD, PL-VT was associated with low LVEF and mortality. In DCM, PL-VT was not associated with mortality but a predictor of VT recurrence independent from LVEF. PL-VT in DCM may indicate a specific arrhythmic substrate difficult to control by current ablation techniques.
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Affiliation(s)
- Yoshitaka Kimura
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
| | - Marta de Riva
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
| | - Micaela Ebert
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Heart Center, University of Leipzig, Germany (M.E.)
| | - Claire Glashan
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
| | - Sebastiaan R Piers
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands (O.M.D.)
| | - Serge A Trines
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
| | - Katja Zeppenfeld
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, The Netherlands, (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.).,Willem Einthoven Center of Arrhythmia Research and Management (Y.K., M.d.R., M.E., C.G., A.P.W., S.R.P., S.A.T., K.Z.)
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Kimura Y, Beukers HKC, Rademaker R, Chen HS, Ebert M, Jensen T, Piers SR, Wijnmaalen AP, de Riva M, Dekkers OM, Stevenson WG, Zeppenfeld K. Volume-Weighted Unipolar Voltage Predicts Heart Failure Mortality in Patients With Dilated Cardiomyopathy and Ventricular Arrhythmias. JACC Clin Electrophysiol 2022:S2405-500X(22)01044-1. [PMID: 36752463 DOI: 10.1016/j.jacep.2022.11.015] [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] [Received: 06/03/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patients with dilated cardiomyopathy (DCM) who are undergoing catheter ablation of ventricular arrhythmias (VAs) are at risk of rapidly progressive heart failure (HF). Endocardial voltages decrease with loss of viable myocardium. Global left ventricular (LV) voltage as a surrogate for the amount of remaining viable myocardium may predict prognosis. OBJECTIVES This study evaluated whether the newly proposed parameter volume-weighted (vw) unipolar voltage (UV) can predict HF-related adverse outcomes (HFOs), including death, heart transplantation, or ventricular assist device implantation, in DCM. METHODS In consecutive patients with DCM referred for VA ablation, vwUV was calculated by mathematically integrating UV over the left ventricle, divided by the endocardial LV surface area and wall thickness. Patients were followed for HFOs. RESULTS A total of 103 patients (57 ± 14 years of age; LV ejection fraction [LVEF], 39 ± 13%) were included. Median vwUV was 9.75 (IQR: 7.27-12.29). During a median follow-up of 24 months (IQR: 8-47 months), 25 patients (24%) died, and 16 had HFOs 7 months (IQR: 1-18 months) after ablation. Patients with HFOs had significantly lower LVEF (29% ± 10% vs 41% ± 12%), vw bipolar voltage (BV) (3.00 [IQR: 2.47-3.53] vs 5.00 [4.12-5.73]), and vwUV (5.94 [IQR: 5.28-6.55] vs 10.37 [IQR: 8.82-12.81]; all P < 0.001), than patients without HFOs. In Cox regression analysis and goodness-of-fit tests, vwUV was the strongest and independent predictor for HFOs (HR: 3.68; CI: 2.09-6.45; likelihood ratio chi-square, 33.05; P < 0.001). CONCLUSIONS The novel parameter vwUV, as a surrogate for the amount of viable myocardium, identifies patients with DCM with VA who are at high risk for HF progression and mortality.
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Affiliation(s)
- Yoshitaka Kimura
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans K C Beukers
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert Rademaker
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - H Sophia Chen
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Micaela Ebert
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Heart Center Dresden, Department of Cardiology, Technical University Dresden, Dresden, Germany
| | - Thomas Jensen
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sebastiaan R Piers
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta de Riva
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - William G Stevenson
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katja Zeppenfeld
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands.
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Lyko C, Blum MR, Abolhassani N, Stuber MJ, Del Giovane C, Feller M, Moutzouri E, Oberle J, Jungo KT, Collet TH, den Elzen WPJ, Poortvliet RKE, Du Puy RS, Dekkers OM, Trompet S, Jukema JW, Aujesky D, Quinn T, Westendorp R, Kearney PM, Gussekloo J, Van Heemst D, Mooijaart SP, Bauer DC, Rodondi N. Thyroid antibodies and levothyroxine effects in subclinical hypothyroidism: A pooled analysis of two randomized controlled trials. J Intern Med 2022; 292:892-903. [PMID: 35894851 PMCID: PMC9796496 DOI: 10.1111/joim.13544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Antithyroid antibodies increase the likelihood of developing overt hypothyroidism, but their clinical utility remains unclear. No large randomized controlled trial (RCT) has assessed whether older adults with subclinical hypothyroidism (SHypo) caused by autoimmune thyroid disease derive more benefits from levothyroxine treatment (LT4). OBJECTIVE To determine whether older adults with SHypo and positive antibodies derive more clinical benefits from LT4 than those with negative antibodies. METHODS We pooled individual participant data from two RCTs, Thyroid Hormone Replacement for Untreated Older Adults with Subclinical Hypothyroidism and IEMO 80+. Participants with persistent SHypo were randomly assigned to receive LT4 or placebo. We compared the effects of LT4 versus placebo in participants with and without anti-thyroid peroxidase (TPO) at baseline. The two primary outcomes were 1-year change in Hypothyroid Symptoms and Tiredness scores on the Thyroid-Related Quality-of-Life Patient-Reported Outcome Questionnaire. RESULTS Among 660 participants (54% women) ≥65 years, 188 (28.5%) had positive anti-TPO. LT4 versus placebo on Hypothyroid Symptoms lead to an adjusted between-group difference of -2.07 (95% confidence interval: -6.04 to 1.90) for positive antibodies versus 0.89 (-1.76 to 3.54) for negative antibodies (p for interaction = 0.31). Similarly, there was no treatment effect modification by baseline antibody status for Tiredness scores-adjusted between-group difference 1.75 (-3.60 to 7.09) for positive antibodies versus 1.14 (-1.90 to 4.19) for negative antibodies (p for interaction = 0.98). Positive anti-TPO were not associated with better quality of life, improvement in handgrip strength, or fewer cardiovascular outcomes with levothyroxine treatment. CONCLUSIONS Among older adults with SHypo, positive antithyroid antibodies are not associated with more benefits on clinical outcomes with LT4.
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Affiliation(s)
- Christina Lyko
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nazanin Abolhassani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Mirah J Stuber
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Elisavet Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jolanda Oberle
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katharina T Jungo
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Tinh-Hai Collet
- Service of Endocrinology, Diabetes, Nutrition and Therapeutic Education, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Wendy P J den Elzen
- Atalmedial Diagnostics Centre, Amsterdam, The Netherlands.,Amsterdam UMC, Department of Clinical Chemistry, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center UMC, Leiden, The Netherlands
| | - Robert S Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center UMC, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology and Metabolic Disorders, Leiden University Medical Center, Leiden, The Netherlands
| | - Stella Trompet
- Department of Internal Medicine-Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Terry Quinn
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences University of Glasgow, Glasgow, UK
| | - Rudi Westendorp
- Department of Public Health and, Center for Healthy Ageing, University of Copenhagen, Copenhagen, Denmark
| | - Patricia M Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center UMC, Leiden, The Netherlands
| | - Diana Van Heemst
- Department of Internal Medicine-Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine-Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Douglas C Bauer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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42
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Husebye ES, Castinetti F, Criseno S, Curigliano G, Decallonne B, Fleseriu M, Higham CE, Lupi I, Paschou SA, Toth M, van der Kooij M, Dekkers OM. Endocrine-related adverse conditions in patients receiving immune checkpoint inhibition: an ESE clinical practice guideline. Eur J Endocrinol 2022; 187:G1-G21. [PMID: 36149449 PMCID: PMC9641795 DOI: 10.1530/eje-22-0689] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized cancer treatment but are associated with significant autoimmune endocrinopathies that pose both diagnostic and treatment challenges. The aim of this guideline is to provide clinicians with the best possible evidence-based recommendations for treatment and follow-up of patients with ICI-induced endocrine side-effects based on the Grading of Recommendations Assessment, Development, and Evaluation system. As these drugs have been used for a relatively short time, large systematic investigations are scarce. A systematic approach to diagnosis, treatment, and follow-up is needed, including baseline tests of endocrine function before each treatment cycle. We conclude that there is no clear evidence for the benefit of high-dose glucocorticoids to treat endocrine toxicities with the possible exceptions of severe thyroid eye disease and hypophysitis affecting the visual apparatus. With the exception of thyroiditis, most endocrine dysfunctions appear to be permanent regardless of ICI discontinuation. Thus, the development of endocrinopathies does not dictate a need to stop ICI treatment.
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Affiliation(s)
- Eystein S Husebye
- Department of Clinical Science and K.G. Jebsen Center of Autoimmune Diseases, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Correspondence should be addressed to E S Husebye;
| | - Frederik Castinetti
- Aix Marseille Univ, INSERM U1251, Marseille Medical genetics, Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, 13005 Marseille, France
| | - Sherwin Criseno
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Giuseppe Curigliano
- Department of Oncology and Hematology, University of Milan, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Department of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Isabella Lupi
- Endocrine Unit, Pisa University Hospital, Pisa, Italy
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Miklos Toth
- Department of Internal Medicine and Oncology, ENETS Center of Excellence, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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43
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Jansen MS, Dekkers OM, Groenwold RHH, Siegerink B. Publication rates in small German trials remained low five years after trial completion. Contemp Clin Trials 2022; 121:106899. [PMID: 36038002 DOI: 10.1016/j.cct.2022.106899] [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] [Received: 04/25/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To investigate publication rates in small trials and to explore which factors are associated with publication rates in small trials, including sample size, the type and number of primary and secondary outcomes. STUDY DESIGN AND SETTING We studied a subgroup of 'small' trials from a pre-existing dataset (IntoValue), containing German trials completed between 2009 and 2017. Small trials were defined as phase II-III, III and IV trials with 150 or fewer participants. We performed an updated publication search and collected additional data from online trial records. RESULTS Out of 499 trials, 325 (65%) trials published their results in a journal article or dissertation. Median time-to-publication was 3.41 years (95% CI: 3.04-4.10). Planned sample size was not associated with publication rates, but the difference between planned and achieved sample size was (per 10% unsuccessfully recruited participants, HR = 0.95, 95% CI: 0.91-1.00). Phase III vs. II-III trials, studied intervention (device vs. other) and clearly vs. unclearly defined primary outcomes predicted a higher likelihood of earlier publication. CONCLUSION About 35% of small trials in Germany remain unpublished, even after an extensive follow-up period of over 9 years. Publication rates are low and were associated with sample size, trial phase and type of intervention.
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Affiliation(s)
- M S Jansen
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, the Netherlands; Department of Endocrinology and Metabolic Disorders, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - R H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - B Siegerink
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, the Netherlands; Directorate of Research Policy, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands.
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44
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Burman P, Trouillas J, Losa M, McCormack A, Petersenn S, Popovic V, Theodoropoulou M, Raverot G, Dekkers OM. Aggressive pituitary tumours and carcinomas, characteristics and management of 171 patients. Eur J Endocrinol 2022; 187:593-605. [PMID: 36018781 PMCID: PMC9513638 DOI: 10.1530/eje-22-0440] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/26/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe clinical and pathological characteristics and treatment outcomes in a large cohort of aggressive pituitary tumours (APT)/pituitary carcinomas (PC). DESIGN Electronic survey August 2020-May 2021. RESULTS 96% of 171 (121 APT, 50 PC), initially presented as macro/giant tumours, 6 were microadenomas (5 corticotroph). Ninety-seven tumours, initially considered clinically benign, demonstrated aggressive behaviour after 5.5 years (IQR: 2.8-12). Of the patients, 63% were men. Adrenocorticotrophic hormone (ACTH)-secreting tumours constituted 30% of the APT/PC, and the gonadotroph subtypes were under-represented. Five out of 13 silent corticotroph tumours and 2/6 silent somatotroph tumours became secreting. Metastases were observed after median 6.3 years (IQR 3.7-12.1) from diagnosis. At the first surgery, the Ki67 index was ≥3% in 74/93 (80%) and ≥10% in 38/93 (41%) tumours. An absolute increase of Ki67 ≥ 10% after median of 6 years from the first surgery occurred in 18/49 examined tumours. Tumours with an aggressive course from outset had higher Ki67, mitotic counts, and p53. Temozolomide treatment in 156/171 patients resulted in complete response in 9.6%, partial response in 30.1%, stable disease in 28.1%, and progressive disease in 32.2% of the patients. Treatment with bevacizumab, immune checkpoint inhibitors, and peptide receptor radionuclide therapy resulted in partial regression in 1/10, 1/6, and 3/11, respectively. Median survival in APT and PC was 17.2 and 11.3 years, respectively. Tumours with Ki67 ≥ 10% and ACTH-secretion were associated with worse prognosis. CONCLUSION APT/PCs exhibit a wide and challenging spectrum of behaviour. Temozolomide is the first-line chemotherapy, and other oncological therapies are emerging. Treatment response continues to be difficult to predict with currently studied biomarkers.
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Affiliation(s)
- Pia Burman
- Department of Endocrinology, Skåne University Hospital Malmö, University of Lund, Lund, Sweden
- Correspondence should be addressed to P Burman;
| | | | - Marco Losa
- Marco Losa Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Ann McCormack
- St Vincent’s Hospital and Garvan Institute of Medical Research, Sydney, Australia
| | | | | | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Germany
| | - Gerald Raverot
- Fédération d’Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, University of Lyon-Est de Lyon, Bron, France
| | - Olaf M Dekkers
- Department of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
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45
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van der Meulen M, Amaya JM, Dekkers OM, Meijer OC. Association between use of systemic and inhaled glucocorticoids and changes in brain volume and white matter microstructure: a cross-sectional study using data from the UK Biobank. BMJ Open 2022; 12:e062446. [PMID: 36041764 PMCID: PMC9438037 DOI: 10.1136/bmjopen-2022-062446] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To test the hypothesis that systemic and inhaled glucocorticoid use is associated with changes in grey matter volume (GMV) and white matter microstructure. DESIGN Cross-sectional study. SETTING UK Biobank, a prospective population-based cohort study of adults recruited in the UK between 2006 and 2010. PARTICIPANTS After exclusion based on neurological, psychiatric or endocrinological history, and use of psychotropic medication, 222 systemic glucocorticoid users, 557 inhaled glucocorticoid users and 24 106 controls with available T1 and diffusion MRI data were included. MAIN OUTCOME MEASURES Primary outcomes were differences in 22 volumetric and 14 diffusion imaging parameters between glucocorticoid users and controls, determined using linear regression analyses adjusted for potential confounders. Secondary outcomes included cognitive functioning (six tests) and emotional symptoms (four questions). RESULTS Both systemic and inhaled glucocorticoid use were associated with reduced white matter integrity (lower fractional anisotropy (FA) and higher mean diffusivity (MD)) compared with controls, with larger effect sizes in systemic users (FA: adjusted mean difference (AMD)=-3.7e-3, 95% CI=-6.4e-3 to 1.0e-3; MD: AMD=7.2e-6, 95% CI=3.2e-6 to 1.1e-5) than inhaled users (FA: AMD=-2.3e-3, 95% CI=-4.0e-3 to -5.7e-4; MD: AMD=2.7e-6, 95% CI=1.7e-7 to 5.2e-6). Systemic use was also associated with larger caudate GMV (AMD=178.7 mm3, 95% CI=82.2 to 275.0), while inhaled users had smaller amygdala GMV (AMD=-23.9 mm3, 95% CI=-41.5 to -6.2) than controls. As for secondary outcomes, systemic users performed worse on the symbol digit substitution task (AMD=-0.17 SD, 95% CI=-0.34 to -0.01), and reported more depressive symptoms (OR=1.76, 95% CI=1.25 to 2.43), disinterest (OR=1.84, 95% CI=1.29 to 2.56), tenseness/restlessness (OR=1.78, 95% CI=1.29 to 2.41), and tiredness/lethargy (OR=1.90, 95% CI=1.45 to 2.50) compared with controls. Inhaled users only reported more tiredness/lethargy (OR=1.35, 95% CI=1.14 to 1.60). CONCLUSIONS Both systemic and inhaled glucocorticoid use are associated with decreased white matter integrity and limited changes in GMV. This association may contribute to the neuropsychiatric side effects of glucocorticoid medication, especially with chronic use.
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Affiliation(s)
- Merel van der Meulen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jorge Miguel Amaya
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
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46
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van der Endt VHW, Milders J, Penning de Vries BBL, Trines SA, Groenwold RHH, Dekkers OM, Trevisan M, Carrero JJ, van Diepen M, Dekker FW, de Jong Y. Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation. Europace 2022; 24:1739-1753. [PMID: 35894866 PMCID: PMC9681133 DOI: 10.1093/europace/euac096] [Citation(s) in RCA: 10] [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] [Received: 12/20/2021] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS Multiple risk scores to predict ischaemic stroke (IS) in patients with atrial fibrillation (AF) have been developed. This study aims to systematically review these scores, their validations and updates, assess their methodological quality, and calculate pooled estimates of the predictive performance. METHODS AND RESULTS We searched PubMed and Web of Science for studies developing, validating, or updating risk scores for IS in AF patients. Methodological quality was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). To assess discrimination, pooled c-statistics were calculated using random-effects meta-analysis. We identified 19 scores, which were validated and updated once or more in 70 and 40 studies, respectively, including 329 validations and 76 updates-nearly all on the CHA2DS2-VASc and CHADS2. Pooled c-statistics were calculated among 6 267 728 patients and 359 373 events of IS. For the CHA2DS2-VASc and CHADS2, pooled c-statistics were 0.644 [95% confidence interval (CI) 0.635-0.653] and 0.658 (0.644-0.672), respectively. Better discriminatory abilities were found in the newer risk scores, with the modified-CHADS2 demonstrating the best discrimination [c-statistic 0.715 (0.674-0.754)]. Updates were found for the CHA2DS2-VASc and CHADS2 only, showing improved discrimination. Calibration was reasonable but available for only 17 studies. The PROBAST indicated a risk of methodological bias in all studies. CONCLUSION Nineteen risk scores and 76 updates are available to predict IS in patients with AF. The guideline-endorsed CHA2DS2-VASc shows inferior discriminative abilities compared with newer scores. Additional external validations and data on calibration are required before considering the newer scores in clinical practice. CLINICAL TRIAL REGISTRATION ID CRD4202161247 (PROSPERO).
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Affiliation(s)
| | - Jet Milders
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Bas B L Penning de Vries
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands,Department of Internal Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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47
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Papadimitropoulou K, Riley RD, Dekkers OM, Stijnen T, le Cessie S. MA-cont:pre/post effect size: An interactive tool for the meta-analysis of continuous outcomes using R Shiny. Res Synth Methods 2022; 13:649-660. [PMID: 35841123 PMCID: PMC9546083 DOI: 10.1002/jrsm.1592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/23/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022]
Abstract
Meta‐analysis is a widely used methodology to combine evidence from different sources examining a common research phenomenon, to obtain a quantitative summary of the studied phenomenon. In the medical field, multiple studies investigate the effectiveness of new treatments and meta‐analysis is largely performed to generate the summary (average) treatment effect. In the meta‐analysis of aggregate continuous outcomes measured in a pretest‐posttest design using differences in means as the effect measure, a plethora of methods exist: analysis of final (follow‐up) scores, analysis of change scores and analysis of covariance. Specialised and general‐purpose statistical software is used to apply the various methods, yet, often the choice among them depends on data availability and statistical affinity. We present a new web‐based tool, MA‐cont:pre/post effect size, to conduct meta‐analysis of continuous data assessed pre‐ and post‐treatment using the aforementioned approaches on aggregate data and a more flexible approach of generating and analysing pseudo individual participant data. The interactive web environment, available by R Shiny, is used to create this free‐to‐use statistical tool, requiring no programming skills by the users. A basic statistical understanding of the methods running in the background is a prerequisite and we encourage the users to seek advice from technical experts when necessary.
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Affiliation(s)
- Katerina Papadimitropoulou
- Clinical Epidemiology, Leiden University Medical Center, The Netherlands.,Data Science & Biometrics, Danone Nutricia Research - Utrecht, The Netherlands
| | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care & Health Sciences, Keele University, England
| | - Olaf M Dekkers
- Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Theo Stijnen
- Biomedical Data Sciences, Leiden University Medical Center, The Netherlands
| | - Saskia le Cessie
- Clinical Epidemiology, Leiden University Medical Center, The Netherlands.,Biomedical Data Sciences, Leiden University Medical Center, The Netherlands
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48
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Krom A, Dekkers OM, Ploem MC. [Don't lose sight of the disadvantages of screening: concerns on proposed amendments of the Dutch Population Screening Act]. Ned Tijdschr Geneeskd 2022; 166:D6701. [PMID: 35736392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
There are more and more possibilities to screen individuals early for health problems or risks thereof. When it comes to screening, it is tempting to think: the sooner a disease (risk) is detected, the better. But screening also has disadvantages, such as distress and fear among participants and the need for further diagnostics in the event of a positive result, with all the related medical risks and burden on the health care system. In short, screening is only useful if the benefits outweigh the disadvantages. In this article we discuss - by means of examples - ethical considerations relevant for weighing the benefits and disadvantages of screening. In closing we reflect on future legislation pertaining to screening that - in our opinion - leaves too much leeway for screening of which the disadvantages outweigh the benefits.
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Affiliation(s)
- André Krom
- Leids Universitair Medisch Centrum, Sectie Ethiek en Recht van de Gezondheidszorg, Leiden
- Contact: André Krom
| | - Olaf M Dekkers
- Leids Universitair Medisch Centrum, afd. Interne Geneeskunde, Leiden
| | - M C Ploem
- Amsterdam UMC, afd. Ethiek, Recht en Humaniora, Amsterdam
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49
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Rademaker R, Kimura Y, Beukers HC, Piers SR, Wijnmaalen AP, De Riva Silva M, Dekkers OM, Zeppenfeld K. Area weighted unipolar voltage to predict heart failure death in patients with ischemic cardiomyopathy and ventricular tachycardia. Europace 2022. [DOI: 10.1093/europace/euac053.361] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Patients with ischemic cardiomyopathy (ICM) referred for catheter ablation (CA) of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodeling of the left ventricle (LV). Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV mapping derived parameter that corrects for oversampling of the infarct area may reflect the total amount of remaining LV viable myocardium.
Objective
To evaluate if the newly proposed parameter, `area weighted unipolar voltage’ (awUV), can predict HF related death/LVAD/Heart transplant (HFD) in ICM.
Methods
Voltage maps from consecutive patients with ICM referred for CA of VT, were transferred to Paraview after valve area removal. AwUV was calculated by mathematically interpolating all mapping points weighted for relative distances divided by the LV endocardial surface. Unipolar low voltage areas (ULVA, UV<8.27mV) were measured as percentage of the total LV surface. Associations between clinical and mapping derived parameters and HFD (HF-related death/LVAD/heart transplant) were evaluated and validated in a second cohort of consecutive patients.
Results
Eighty-nine patients in the study group (age 68±8; LVEF 33% [IQR 24-40%]; ULVA 64% [IQR 46-86%]; awUV 7.01 [IQR 5.01-8.52]) and 69 patients in the validation group (age 68±9; LVEF 39% [IQR 29-44%]; ULVA 59% [IQR 43-77%]; awUV 7.60 [IQR 6.16-8.69]) were included. Follow-up was 32±17 months in the study group, 28±17 months in the validation group. HFD was 20% in the study group, 10% in the validation cohort. Patients with HFD had lower LVEF and awUV, and larger ULVA than patients without HFD (LVEF 23±10% vs. 35±11%; awUV: 5.12±1.92 vs. 7.75±2.64; LVA 86±21% vs. 60±23%, all P<0.001). Univariable analysis showed that LVEF, ULVA and awUV were associated with HFD (HR and 95% CI: LVEF 1.10 [1.05 – 1.16]; LVA 1.05 [1.02 – 1.08]; awUV 2.18 [1.58 – 3.40], all P<0.01). AwUV was superior to ULVA to predict HFD in likelihood ratio calculations (awUV: LR 5.66, P=0.02; LVA: 1.76 P=0.18) and ROC analysis (AUC awUV: 0.86; LVA 0.78). The optimal cut-off for awUV of<5.27 was highly accurate to predict HFD in the validation cohort (log-rank P<0.001).
Conclusion
The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at risk for HFD.
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Affiliation(s)
- R Rademaker
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
| | - Y Kimura
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
| | - HC Beukers
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
| | - SR Piers
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
| | - AP Wijnmaalen
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
| | - M De Riva Silva
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
| | - OM Dekkers
- Leiden University Medical Center, Leiden, Netherlands (The)
| | - K Zeppenfeld
- Leiden University Medical Center, Electrophysiology, Leiden, Netherlands (The)
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50
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Du Puy RS, Poortvliet RKE, Mooijaart SP, Stott DJ, Quinn T, Sattar N, Westendorp RGJ, Kearney PM, McCarthy VJC, Byrne S, Rodondi N, Baretella O, Collet TH, van Heemst D, Dekkers OM, Jukema JW, Smit JWA, Gussekloo J, den Elzen WPJ. No Effect of Levothyroxine on Hemoglobin in Older Adults With Subclinical Hypothyroidism: Pooled Results From 2 Randomized Controlled Trials. J Clin Endocrinol Metab 2022; 107:e2339-e2347. [PMID: 35218666 PMCID: PMC9113813 DOI: 10.1210/clinem/dgac106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Indexed: 02/07/2023]
Abstract
CONTEXT Subclinical thyroid dysfunction and anemia are common disorders, and both have increasing prevalence with advancing age. OBJECTIVE The aim of this study was to assess whether levothyroxine treatment leads to a rise in hemoglobin levels in older persons with subclinical hypothyroidism. METHODS This preplanned combined analysis of 2 randomized controlled trials included community-dwelling persons aged 65 years and older with subclinical hypothyroidism who were randomly assigned to levothyroxine or placebo treatment. The levothyroxine dose was periodically titrated aiming at thyroid stimulating hormone (TSH) level within the reference range, with mock titrations in the placebo group. The main outcome measure was the change in hemoglobin level after 12 months. RESULTS Analyses included 669 participants (placebo n = 337, levothyroxine n = 332) with a median age of 75 years (range, 65-97) and mean baseline hemoglobin of 13.8 ± 1.3 g/dL. Although levothyroxine treatment resulted in a reduction in TSH from baseline after 12 months of follow-up compared with placebo, the change in hemoglobin level was not different between the levothyroxine and the placebo groups (-0.03 g/dL [95% CI, -0.16 to 0.11]). Similar results were found in stratified analyses including sex, age, or TSH levels. No difference in change of hemoglobin levels after 12 months was identified in 69 participants with anemia at baseline (-0.33 g/dL [95% CI, -0.87 to 0.21]). CONCLUSION In persons aged 65 years and older with subclinical hypothyroidism, treatment with levothyroxine does not lead to a rise in hemoglobin levels, regardless of the presence of anemia.
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Affiliation(s)
- Robert S Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center, ZA Leiden, the Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, ZA Leiden, the Netherlands
- Correspondence: Rosalinde Poortvliet, Department of Public Health and Primary Care, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.
| | - Simon P Mooijaart
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, ZA Leiden, the Netherlands
- Institute for Evidence-based Medicine in Old age, ZA Leiden, the Netherlands
| | - David J Stott
- Department of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terry Quinn
- Department of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Rudi G J Westendorp
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | | | - Vera J C McCarthy
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Stephen Byrne
- School of Pharmacy, University College Cork, Cork, Cork, Ireland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Oliver Baretella
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Tinh-Hai Collet
- Service of Endocrinology, Diabetes, Nutrition and Therapeutic Education, Geneva University Hospitals, Switzerland
| | - Diana van Heemst
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, ZA Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology and metabolic disorders, Leiden University Medical Center, ZA Leiden, the Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, ZA Leiden, the Netherlands
- Netherlands Heart Institute, EP Utrecht, the Netherlands
| | | | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, ZA Leiden, the Netherlands
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, ZA Leiden, the Netherlands
| | - Wendy P J den Elzen
- Atalmedial Diagnostics Centre, EC Amsterdam, the Netherlands
- Amsterdam UMC, Department of Clinical Chemistry, Amsterdam Public Health Research Institute, HV Amsterdam, the Netherlands
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