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Gray CM, Wyke S, Zhang R, Anderson AS, Barry S, Boyer N, Brennan G, Briggs A, Bunn C, Donnachie C, Grieve E, Kohli-Lynch C, Lloyd SM, McConnachie A, McCowan C, MacLean A, Mutrie N, Hunt K. Long-term weight loss trajectories following participation in a randomised controlled trial of a weight management programme for men delivered through professional football clubs: a longitudinal cohort study and economic evaluation. Int J Behav Nutr Phys Act 2018; 15:60. [PMID: 29954449 PMCID: PMC6022303 DOI: 10.1186/s12966-018-0683-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 05/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obesity is a major public health concern requiring innovative interventions that support people to lose weight and keep it off long term. However, weight loss maintenance remains a challenge and is under-researched, particularly in men. The Football Fans in Training (FFIT) programme engages men in weight management through their interest in football, and encourages them to incorporate small, incremental physical activity and dietary changes into daily life to support long-term weight loss maintenance. In 2011/12, a randomised controlled trial (RCT) of FFIT demonstrated effectiveness and cost-effectiveness at 12 months. The current study aimed to investigate long-term maintenance of weight loss, behavioural outcomes and lifetime cost-effectiveness following FFIT. METHODS A longitudinal cohort study comprised 3.5-year follow-up of the 747 FFIT RCT participants. Men aged 35-65 years, BMI ≥ 28 kg/m2 at RCT baseline who consented to long-term follow-up (n = 665) were invited to participate: those in the FFIT Follow Up Intervention group (FFIT-FU-I) undertook FFIT in 2011 during the RCT; the FFIT Follow Up Comparison group (FFIT-FU-C) undertook FFIT in 2012 under routine (non-research) conditions. The primary outcome was objectively-measured weight loss (from baseline) at 3.5 years. Secondary outcomes included changes in self-reported physical activity and diet at 3.5 years. Cost-effectiveness was estimated at 3.5 years and over participants' lifetime. RESULTS Of 665 men invited, 488 (73%; 65% of the 747 RCT participants) attended 3.5-year measurements. The FFIT-FU-I group sustained a mean weight loss of 2.90 kg (95% CI 1.78, 4.02; p < 0.001) 3.5 years after starting FFIT; 32.2% (75/233) weighed ≥5% less than baseline. The FFIT-FU-C group had lost 2.71 kg (1.65, 3.77; p < 0.001) at the 3.5-year measurements (2.5 years after starting FFIT); 31.8% (81/255) weighed ≥5% less than baseline. There were significant sustained improvements in self-reported physical activity and diet in both groups. The estimated incremental cost-effectiveness of FFIT was £10,700-£15,300 per QALY gained at 3.5 years, and £1790-£2200 over participants' lifetime. CONCLUSIONS Participation in FFIT under research and routine conditions leads to long-term weight loss and improvements in physical activity and diet. Investment in FFIT is likely to be cost-effective as part of obesity management strategies in countries where football is popular. TRIAL REGISTRATION ISRCTN32677491 , 20 October 2011.
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Affiliation(s)
- Cindy M. Gray
- School of Social and Political Sciences, Institute of Health and Wellbeing, 25-29 Bute Gardens, University of Glasgow, Glasgow, G12 8RS UK
| | - Sally Wyke
- School of Social and Political Sciences, Institute of Health and Wellbeing, 25-29 Bute Gardens, University of Glasgow, Glasgow, G12 8RS UK
| | - Ruiqi Zhang
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow, G12 8QQ UK
| | - Annie S. Anderson
- Centre for Public Health Nutrition Research, Mailbox 7, Level 7, Ninewells Medical School, University of Dundee, Dundee, DD1 9SY UK
| | - Sarah Barry
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow, G12 8QQ UK
| | - Nicki Boyer
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, 1 Lilybank Gardens, University of Glasgow, Glasgow, G12 8RZ UK
| | - Graham Brennan
- Institute of Health and Wellbeing, 25-29 Bute Gardens, University of Glasgow, Glasgow, G12 8RS UK
| | - Andrew Briggs
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, 1 Lilybank Gardens, University of Glasgow, Glasgow, G12 8RZ UK
| | - Christopher Bunn
- Institute of Health and Wellbeing, 25-29 Bute Gardens, University of Glasgow, Glasgow, G12 8RS UK
| | - Craig Donnachie
- Institute for Social Marketing, Faculty of Health Sciences and Sport, University of Stirling, Glasgow, FK9 4LA UK
| | - Eleanor Grieve
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, 1 Lilybank Gardens, University of Glasgow, Glasgow, G12 8RZ UK
| | - Ciaran Kohli-Lynch
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, 1 Lilybank Gardens, University of Glasgow, Glasgow, G12 8RZ UK
| | - Suzanne M. Lloyd
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow, G12 8QQ UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow, G12 8QQ UK
| | - Colin McCowan
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow, G12 8QQ UK
| | - Alice MacLean
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB UK
| | - Nanette Mutrie
- Institute for Sport, Physical Education and Health Sciences, University of Edinburgh, 2.27 St Leonard’s Land, Holyrood Road, Edinburgh, EH8 8AQ UK
| | - Kate Hunt
- Institute for Social Marketing, Faculty of Health Sciences and Sport, University of Stirling, Glasgow, FK9 4LA UK
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Lloyd SM, Crawford G, McSkimming P, Grifi M, Greenwell TJ, Ockrim JL. The impact of age, gender and severity of overactive bladder wet on quality of life, productivity, treatment patterns and satisfaction. Journal of Clinical Urology 2017. [DOI: 10.1177/2051415817710111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Objective: The objective of this article is to determine the impact of idiopathic overactive bladder wet (OAB wet) severity, age and gender on health-related quality of life (HRQoL), productivity, treatment patterns and treatment satisfaction. Materials and methods: A prospective, cross-sectional online survey of adults in the United Kingdom was performed to screen for self-reported symptoms of OAB wet. Respondents completed the King’s Health Questionnaire or the Incontinence Quality of Life, as well as the Euroqol 5D, and the Work Productivity and Activity Impairment Specific Health Problem questionnaire, and questions pertaining to distress, treatment and treatment satisfaction. Results: A total of 249 of 1126 respondents (22.1%) met the criteria for OAB wet. Respondents with moderate/severe OAB wet and all women experienced significantly worse HRQoL and work productivity than those with mild symptoms and all men, respectively. Among all OAB wet responders, 62.7% were receiving treatment for their condition, predominantly pads (40.2%); only 1.6% were receiving specialised treatment. Nearly one-half (44.6%) were somewhat or completely dissatisfied with their current treatment. Conclusion: In individuals with OAB wet, severity and gender negatively impact HRQoL and work productivity. A substantial proportion of OAB wet individuals were untreated, and low treatment satisfaction was reported in those receiving treatment. Treatment was generally conservative.
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Affiliation(s)
- SM Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, UK
| | | | - P McSkimming
- Robertson Centre for Biostatistics, University of Glasgow, UK
| | - M Grifi
- Reimbursement and Health Economics, Medtronic International Trading Sàrl, Switzerland
| | - TJ Greenwell
- Institute of Urology, University College Hospital London, UK
| | - JL Ockrim
- Institute of Urology, University College Hospital London, UK
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Jonkman NH, Westland H, Trappenburg JC, Groenwold RH, Bischoff EW, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton MJ, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJ, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:2063-74. [PMID: 27621612 PMCID: PMC5012618 DOI: 10.2147/copd.s107884] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most. Methods Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models. Results Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes. Conclusion Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.
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Affiliation(s)
- Nini H Jonkman
- Department of Rehabilitation, Nursing Science and Sports
| | | | | | - Rolf Hh Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | - Erik Wma Bischoff
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada
| | | | - David Coultas
- Veterans Administration Portland Health Care System and Oregon Health & Science University, Portland, OR, USA
| | - Tanja W Effing
- Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, SA, Australia
| | - Michael J Epton
- Canterbury District Health Board, Respiratory Services, Christchurch Hospital, Christchurch, New Zealand
| | - Frode Gallefoss
- Department of Pulmonary Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Judith Garcia-Aymerich
- Centre for Research in Environmental Epidemiology CREAL; Pompeu Fabra University; CIBER Epidemiología y Salud Pública CIBERESP, Barcelona, Spain
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Job van der Palen
- Department of Research Methodology, Measurement and Data Analysis, University of Twente; Department of Clinical Epidemiology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Kathryn L Rice
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis Veterans Affairs Health Care Service and University of Minnesota, Minneapolis, MN, USA
| | - Maria Sedeno
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Stephanie Jc Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Thierry Troosters
- Department of Rehabilitation Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
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Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, Boyer N, McConnachie A, Lloyd SM, O'Brien R, Watt GCM, Wyke S. The CARE Plus study - a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis. BMC Med 2016; 14:88. [PMID: 27328975 PMCID: PMC4916534 DOI: 10.1186/s12916-016-0634-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [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] [Received: 12/30/2015] [Accepted: 06/02/2016] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation. METHODS We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat. RESULTS Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11-0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86-£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028-0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue. CONCLUSIONS It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas. TRIAL REGISTRATION TRIAL REGISTRATION ISRCTN 34092919 , assigned 14/1/2013.
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Affiliation(s)
- Stewart W Mercer
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Elisabeth Fenwick
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Eleanor Grieve
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Kenny Lawson
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Nicki Boyer
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Rosaleen O'Brien
- Institute of Applied Health, Glasgow Caledonian University, 4th Floor George Moore Building, Cowcaddens Road, Glasgow, Lanarkshire, G4 0BA, UK
| | - Graham C M Watt
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Sally Wyke
- Institute of Health and Wellbeing, University of Glasgow, 27 Bute Gardens, Glasgow, G12 8RS, UK
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5
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Jonkman NH, Westland H, Trappenburg JCA, Groenwold RHH, Bischoff EWMA, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton M, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJC, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis. Eur Respir J 2016. [PMID: 27126694 DOI: 10.1183/13993003.01860‐2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97-0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92-0.99; RR after 12 months follow-up 0.98, 95% CI 0.96-1.00).Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.
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Affiliation(s)
- Nini H Jonkman
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heleen Westland
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap C A Trappenburg
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik W M A Bischoff
- Dept of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Dept of Medicine, McGill University Health Center, McGill University, Montreal, Canada
| | | | - David Coultas
- Veterans Administration Portland Health Care System and Oregon Health & Science University, Portland, OR, USA
| | - Tanja W Effing
- Dept of Respiratory Medicine, Repatriation General Hospital, Adelaide, Australia
| | - Michael Epton
- Canterbury District Health Board, Respiratory Services, Christchurch Hospital, Christchurch, New Zealand
| | - Frode Gallefoss
- Dept of Pulmonary Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Judith Garcia-Aymerich
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain Universitat Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Huong Q Nguyen
- Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Job van der Palen
- Dept of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands Department of Clinical Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Kathryn L Rice
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis Veterans Affairs Health Care Service and University of Minnesota, Minneapolis, USA
| | - Maria Sedeno
- Respiratory Epidemiology and Clinical Research Unit, Dept of Medicine, McGill University Health Center, McGill University, Montreal, Canada
| | - Stephanie J C Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Thierry Troosters
- Dept of Rehabilitation Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Sydney, Australia
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
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6
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Jonkman NH, Westland H, Trappenburg JC, Groenwold RH, Bischoff EW, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton M, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJ, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis. Eur Respir J 2016; 48:55-68. [DOI: 10.1183/13993003.01860-2015] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/16/2016] [Indexed: 11/05/2022]
Abstract
It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97–0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92–0.99; RR after 12 months follow-up 0.98, 95% CI 0.96–1.00).Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.
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Böhm M, Lloyd SM, Ford I, Borer JS, Ewen S, Laufs U, Mahfoud F, Lopez‐Sendon J, Ponikowski P, Tavazzi L, Swedberg K, Komajda M. Non‐adherence to ivabradine and placebo and outcomes in chronic heart failure: an analysis from
SHIFT. Eur J Heart Fail 2016; 18:672-83. [DOI: 10.1002/ejhf.493] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 12/13/2022] Open
Affiliation(s)
- Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III Homburg/Saar Germany
| | - Suzanne M. Lloyd
- Robertson Centre for Biostatistics University of Glasgow Glasgow UK
| | - Ian Ford
- Robertson Centre for Biostatistics University of Glasgow Glasgow UK
| | - Jeffrey S. Borer
- Division of Cardiovascular Medicine The Howard Gilman Institute for Heart Valve Diseases and the Schiavone Institute for Cardiovascular Translational Research, SUNY Downstate Medical Center Brooklyn and New York NY USA
| | - Sebastian Ewen
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III Homburg/Saar Germany
| | - Ulrich Laufs
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III Homburg/Saar Germany
| | - Felix Mahfoud
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III Homburg/Saar Germany
| | - Jose Lopez‐Sendon
- Hospital Universitario La PAZ, Cardiology Department Instituto de Investigation Madrid Spain
| | | | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation Cotignola Italy
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg Sweden
- National Heart and Lung Institute Imperial College London UK
| | - Michel Komajda
- Istitute of Cardiometabolism and Nutrition (ICAN) Pierre et Marie Curie Paris VI University, La Pitié‐Salpétrière Hospital Paris France
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Mercer SW, Higgins M, Bikker AM, Fitzpatrick B, McConnachie A, Lloyd SM, Little P, Watt GCM. General Practitioners' Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation. Ann Fam Med 2016; 14:117-24. [PMID: 26951586 PMCID: PMC4781514 DOI: 10.1370/afm.1910] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [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: 12/13/2022] Open
Abstract
PURPOSE We set out to compare patients' expectations, consultation characteristics, and outcomes in areas of high and low socioeconomic deprivation, and to examine whether the same factors predict better outcomes in both settings. METHODS Six hundred fifty-nine patients attending 47 general practitioners in high- and low-deprivation areas of Scotland participated. We assessed patients' expectations of involvement in decision making immediately before the consultation and patients' perceptions of their general practitioners' empathy immediately after. Consultations were video recorded and analyzed for verbal and non-verbal physician behaviors. Symptom severity and related well-being were measured at baseline and 1 month post-consultation. Consultation factors predicting better outcomes at 1 month were identified using backward selection methods. RESULTS Patients in deprived areas had less desire for shared decision-making (P <.001). They had more problems to discuss (P = .01) within the same consultation time. Patients in deprived areas perceived their general practitioners (GPs) as less empathic (P = .02), and the physicians displayed verbal and nonverbal behaviors that were less patient centered. Outcomes were worse at 1 month in deprived than in affluent groups (70% response rate; P <.001). Perceived physician empathy predicted better outcomes in both groups. CONCLUSIONS Patients' expectations, GPs' behaviors within the consultation, and health outcomes differ substantially between high- and low-deprivation areas. In both settings, patients' perceptions of the physicians' empathy predict health outcomes. These findings are discussed in the context of inequalities and the "inverse care law."
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Affiliation(s)
- Stewart W Mercer
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Maria Higgins
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Annemieke M Bikker
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Bridie Fitzpatrick
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | - Paul Little
- Primary Medical Care, Aldermoor Health Centre, University of Southampton, Southampton, England
| | - Graham C M Watt
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
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Mathie RT, Van Wassenhoven M, Jacobs J, Oberbaum M, Frye J, Manchanda RK, Roniger H, Dantas F, Legg LA, Clausen J, Moss S, Davidson JR, Lloyd SM, Ford I, Fisher P. Systematic review and meta-analysis of randomised, placebo-controlled, trials of individualised homeopathic treatment. HOMEOPATHY 2016. [DOI: 10.1016/j.homp.2015.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Elliott HL, Lloyd SM, Ford I, Meredith PA. Prognostic importance of pretreatment and on-treatment blood pressure: Further analysis of the ACTION database and the effect of nifedipine gastrointestinal therapeutic system. Blood Press 2016; 25:67-73. [DOI: 10.3109/08037051.2015.1127526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
A retrospective further analysis of the ACTION database evaluated the relationship between cardiovascular outcomes and the "quality" of the control of blood pressure (BP). The study population (n = 6287) comprised those patients with four BP measurements during year 1 subdivided according to the proportion of visits in which BP was controlled in relation to two BP targets: < 140/90mmHg and < 130/80 mmHg. Differences between the BP control groups for the major prespecified ACTION outcomes were investigated with Cox proportional hazards models. For all the prespecified cardiovascular endpoints the incidence declined as the proportion of visits with BP control increased. The greatest differences in outcomes between the different BP control groups were observed for the risk of stroke but were still apparent for all the other endpoints. For example, the risks for the primary outcome [hazard ratio (HR) 0.78; 95% confidence interval (CI) 0.67 to 0.90] were significantly less in the group with >_75% of visits with BP control than in the group with < 25% of visits with BP control. There were no significant treatment-related differences. Retrospective analyses are not definitive but these results highlight the importance of the attainment of BP control targets and the consistency of BP control during long-term follow-up.
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Affiliation(s)
- Peter A Meredith
- a Division of Cardiovascular and Medical Sciences , University of Glasgow , Western Infirmary , Glasgow , UK
| | - Suzanne M Lloyd
- b Robertson Centre for Biostatistics, University of Glasgow , Glasgow , UK
| | - Ian Ford
- b Robertson Centre for Biostatistics, University of Glasgow , Glasgow , UK
| | - Henry L Elliott
- c Institute of Pharmaceutical and Biomedical Sciences, University of Strathclyde , Glasgow , UK
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Mathie RT, Van Wassenhoven M, Jacobs J, Oberbaum M, Frye J, Manchanda RK, Roniger H, Dantas F, Legg LA, Clausen J, Moss S, Davidson JR, Lloyd SM, Ford I, Fisher P. Meta-analysis of randomised, placebo-controlled, trials of individualised homeopathic treatment. Eur J Integr Med 2015. [DOI: 10.1016/j.eujim.2015.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Macfarlane PW, Lloyd SM, Singh D, Hamde S, Clark E, Devine B, Francq BG, Kumar V. Normal limits of the electrocardiogram in Indians. J Electrocardiol 2015; 48:652-68. [DOI: 10.1016/j.jelectrocard.2015.04.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 02/04/2023]
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Poortvliet RKE, Lloyd SM, Ford I, Sattar N, de Craen AJM, Wijsman LW, Mooijaart SP, Westendorp RGJ, Jukema JW, de Ruijter W, Gussekloo J, Stott DJ. Biological correlates of blood pressure variability in elderly at high risk of cardiovascular disease. Am J Hypertens 2015; 28:469-79. [PMID: 25298176 DOI: 10.1093/ajh/hpu181] [Citation(s) in RCA: 9] [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] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Visit-to-visit variability in blood pressure is an independent predictor of cardiovascular disease. This study investigates biological correlates of intra-individual variability in blood pressure in older persons. METHODS Nested observational study within the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) among 3,794 male and female participants (range 70-82 years) with a history of, or risk factors for cardiovascular disease. Individual visit-to-visit variability in systolic and diastolic blood pressure and pulse pressure (expressed as 1 SD in mm Hg) was assessed using nine measurements over 2 years. Correlates of higher visit-to-visit variability were examined at baseline, including markers of inflammation, endothelial function, renal function and glucose homeostasis. RESULTS Over the first 2 years, the mean intra-individual variability (1 SD) was 14.4mm Hg for systolic blood pressure, 7.7mm Hg for diastolic blood pressure, and 12.6mm Hg for pulse pressure. After multivariate adjustment a higher level of interleukin-6 at baseline was consistently associated with higher intra-individual variability of blood pressure, including systolic, diastolic, and pulse pressure. Markers of endothelial function (Von Willebrand factor, tissue plasminogen activator), renal function (glomerular filtration rate) and glucose homeostasis (blood glucose, homeostatic model assessment index) were not or to a minor extent associated with blood pressure variability. CONCLUSION In an elderly population at risk of cardiovascular disease, inflammation (as evidenced by higher levels of interleukin-6) is associated with higher intra-individual variability in systolic, diastolic, and pulse pressure.
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Affiliation(s)
- Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands;
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Anton J M de Craen
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Liselotte W Wijsman
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands; Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands; Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands; Institute for Evidence-Based Medicine in Old Age, Leiden, The Netherlands
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter de Ruijter
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - David J Stott
- Academic Section of Geriatric Medicine, University of Glasgow-Faculty of Medicine, Glasgow Royal Infirmary, Glasgow, UK
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Huang X, Cheripelli BK, Lloyd SM, Kalladka D, Moreton FC, Siddiqui A, Ford I, Muir KW. Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study. Lancet Neurol 2015; 14:368-76. [PMID: 25726502 DOI: 10.1016/s1474-4422(15)70017-7] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In most countries, alteplase given within 4·5 h of onset is the only approved medical treatment for acute ischaemic stroke. The newer thrombolytic drug tenecteplase has been investigated in one randomised trial up to 3 h after stroke and in another trial up to 6 h after stroke in patients selected by advanced neuroimaging. In the Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST), we aimed to assess the efficacy and safety of tenecteplase versus alteplase within 4·5 h of stroke onset in a population not selected on the basis of advanced neuroimaging, and to use imaging biomarkers to inform the design of a definitive phase 3 clinical trial. METHODS In this single-centre, phase 2, prospective, randomised, open-label, blinded end-point evaluation study, adults with supratentorial ischaemic stroke eligible for intravenous thrombolysis within 4·5 h of onset were recruited from The Institute of Neurological Sciences, Glasgow, Scotland. Patients were randomly assigned (1:1) to receive tenecteplase 0·25 mg/kg (maximum 25 mg) or alteplase 0·9 mg/kg (maximum 90 mg). Treatment allocation used a mixed randomisation and minimisation algorithm including age and National Institutes of Health Stroke Scale score, generated by an independent statistician. Patients were not informed of treatment allocation; treating clinicians were aware of allocation but those assessing the primary outcome were not. Imaging comprised baseline CT, CT perfusion, and CT angiography; and CT plus CT angiography at 24-48 h. The primary endpoint was percentage of penumbra salvaged (CT perfusion-defined penumbra volume at baseline minus CT infarct volume at 24-48 h). Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT01472926. FINDINGS Between Jan 1, 2012, and Sept 7, 2013, 355 patients were screened, of whom 157 were eligible for intravenous thrombolysis, and 104 patients were enrolled. 52 were assigned to the alteplase group and 52 to tenecteplase. Of 71 patients (35 assigned tenecteplase and 36 assigned alteplase) contributing to the primary endpoint, no significant differences were noted for percentage of penumbral salvaged (68% [SD 28] for the tenecteplase group vs 68% [23] for the alteplase group; mean difference 1·3% [95% CI -9·6 to 12·1]; p=0·81). Neither incidence of symptomatic intracerebral haemorrhage (by SITS-MOST definition, 1/52 [2%] tenecteplase vs 2/51 [4%] alteplase, p=0·55; by ECASS II definition, 3/52 [6%] vs 4/51 [8%], p=0·59) nor total intracerebral haemorrhage events (8/52 [15%] vs 14/51 [29%], p=0·091) differed significantly. The incidence of serious adverse events did not differ between groups (32 in the tenecteplase group, three considered probably or definitely related to drug treatment; 16 in the alteplase group, five were considered drug-related). INTERPRETATION Neurological and radiological outcomes did not differ between the tenecteplase and alteplase groups. Evaluation of tenecteplase in larger trials of patients with acute stroke seems warranted. FUNDING The Stroke Association.
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Affiliation(s)
- Xuya Huang
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Bharath Kumar Cheripelli
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Dheeraj Kalladka
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Fiona Catherine Moreton
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, Southern General Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK.
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Böhm M, Borer JS, Camm J, Ford I, Lloyd SM, Komajda M, Tavazzi L, Talajic M, Lainscak M, Reil JC, Ukena C, Swedberg K. Twenty-four-hour heart rate lowering with ivabradine in chronic heart failure: insights from the SHIFT Holter substudy. Eur J Heart Fail 2015; 17:518-26. [DOI: 10.1002/ejhf.258] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/23/2014] [Accepted: 01/09/2015] [Indexed: 01/18/2023] Open
Affiliation(s)
- Michael Böhm
- Universitätsklinikum des Saarlandes; Klinik für Innere Medizin III Homburg/Saar Germany
| | - Jeffrey S. Borer
- Division of Cardiovascular Medicine; The Howard Gilman Institute for Heart Valve Diseases and the Schiavone Institute for Cardiovascular Translational Research; SUNY Downstate Medical Center Brooklyn and New York, NY USA
| | - John Camm
- Division of Clinical Sciences; St George's University of London; London UK
| | - Ian Ford
- Robertson Centre for Biostatistics; University of Glasgow; Glasgow UK
| | - Suzanne M. Lloyd
- Robertson Centre for Biostatistics; University of Glasgow; Glasgow UK
| | - Michel Komajda
- Groupe Hospitalier Pitie-Salpetriere; Faculte de medicine Paris France
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotingola Italy
| | | | - Mitja Lainscak
- University Clinic Golnik; Division of Cardiology; Slovenia
| | - Jan-Christian Reil
- Universitätsklinikum des Saarlandes; Klinik für Innere Medizin III Homburg/Saar Germany
| | - Christian Ukena
- Universitätsklinikum des Saarlandes; Klinik für Innere Medizin III Homburg/Saar Germany
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy; University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College; London
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Mathie RT, Lloyd SM, Legg LA, Clausen J, Moss S, Davidson JRT, Ford I. Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis. Syst Rev 2014; 3:142. [PMID: 25480654 PMCID: PMC4326322 DOI: 10.1186/2046-4053-3-142] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [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] [Received: 06/26/2014] [Accepted: 11/12/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND A rigorous and focused systematic review and meta-analysis of randomised controlled trials (RCTs) of individualised homeopathic treatment has not previously been undertaken. We tested the hypothesis that the outcome of an individualised homeopathic treatment approach using homeopathic medicines is distinguishable from that of placebos. METHODS The review's methods, including literature search strategy, data extraction, assessment of risk of bias and statistical analysis, were strictly protocol-based. Judgment in seven assessment domains enabled a trial's risk of bias to be designated as low, unclear or high. A trial was judged to comprise 'reliable evidence' if its risk of bias was low or was unclear in one specified domain. 'Effect size' was reported as odds ratio (OR), with arithmetic transformation for continuous data carried out as required; OR > 1 signified an effect favouring homeopathy. RESULTS Thirty-two eligible RCTs studied 24 different medical conditions in total. Twelve trials were classed 'uncertain risk of bias', three of which displayed relatively minor uncertainty and were designated reliable evidence; 20 trials were classed 'high risk of bias'. Twenty-two trials had extractable data and were subjected to meta-analysis; OR = 1.53 (95% confidence interval (CI) 1.22 to 1.91). For the three trials with reliable evidence, sensitivity analysis revealed OR = 1.98 (95% CI 1.16 to 3.38). CONCLUSIONS Medicines prescribed in individualised homeopathy may have small, specific treatment effects. Findings are consistent with sub-group data available in a previous 'global' systematic review. The low or unclear overall quality of the evidence prompts caution in interpreting the findings. New high-quality RCT research is necessary to enable more decisive interpretation.
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Welsh P, Preiss D, Lloyd SM, de Craen AJ, Jukema JW, Westendorp RG, Buckley BM, Kearney PM, Briggs A, Stott DJ, Ford I, Sattar N. Contrasting associations of insulin resistance with diabetes, cardiovascular disease and all-cause mortality in the elderly: PROSPER long-term follow-up. Diabetologia 2014; 57:2513-20. [PMID: 25264116 DOI: 10.1007/s00125-014-3383-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/29/2014] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS Insulin resistance is commonly proposed as a precursor to both type 2 diabetes and cardiovascular disease (CVD), yet few studies have directly compared insulin resistance with both outcomes simultaneously and determined whether associations with each outcome differ in strength or are comparable. We assessed the association of fasting insulin and HOMA-IR with incident CVD and diabetes in older people. METHODS In the long-term follow-up of the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) cohort, HOMA-IR measurement was available in 4,742 older people (70-82 years) without diabetes at baseline. Of these, 283 developed diabetes during the 3.2 year within-trial follow-up, while 1,943 all-cause deaths, 470 CHD deaths (identified from death records) and 590 fatal/non-fatal CVD events (identified from medical record linkage in the Scottish participants) occurred during an extended 8.6 years of total follow-up. Cause-specific Cox proportional-hazards models were fitted using multivariable models. RESULTS Higher HOMA-IR was associated with incident diabetes: HR 4.80 (95% CI 3.14, 7.33) comparing extreme thirds after adjustment for confounders. However, HOMA-IR in the top third was not associated with all-cause mortality, CHD mortality or fatal/non-fatal CVD: HR 1.02 (95% CI 0.90, 1.17), 1.03 (0.79, 1.36) and 0.94 (0.74, 1.20), respectively. Results were similar when fasting insulin was considered as an exposure. CONCLUSIONS/INTERPRETATION Our data support insulin resistance as a predictor of diabetes in later life but, perhaps surprisingly, suggest this pathway is of negligible importance to CVD outcomes in the elderly.
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Affiliation(s)
- Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK,
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Lowrie R, Lloyd SM, McConnachie A, Morrison J. A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care. PLoS One 2014; 9:e113370. [PMID: 25405478 PMCID: PMC4236200 DOI: 10.1371/journal.pone.0113370] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 10/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year. Methods We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years. Findings We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later. Interpretation Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population. Trial Registration International Standard Randomised Controlled Trials Register ISRCTN61233866
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Affiliation(s)
- Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Suzanne M. Lloyd
- Robertson Centre for Biostatistics, Boyd Orr Building, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Boyd Orr Building, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Jill Morrison
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
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Bots ML, Ford I, Lloyd SM, Laurent S, Touboul PJ, Hennerici MG. Thromboxane prostaglandin receptor antagonist and carotid atherosclerosis progression in patients with cerebrovascular disease of ischemic origin: a randomized controlled trial. Stroke 2014; 45:2348-53. [PMID: 25070960 DOI: 10.1161/strokeaha.114.004775] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Thromboxane prostaglandin receptors have been implicated to be involved in the atherosclerotic process. We assessed whether Terutroban, a thromboxane prostaglandin receptor antagonist, affects the progression of atherosclerosis, as measured by common carotid intima-media thickness and carotid plaques. METHODS A substudy was performed among 1141 participants of the aspirin-controlled Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin with Terutroban in Patients with a History of Ischemic Stroke or Transient Ischemic Attack (PERFORM) trial. Common carotid intima-media thickness and carotid plaque occurrence was measured during a 3-year period. RESULTS Baseline characteristics did not differ between Terutroban (n=592) and aspirin (n=549) treated patients and were similar as in the main study. Mean study and treatment duration were similar (28 and 25 months, respectively). In the Terutroban group, the annualized rate of change in common carotid intima-media thickness was 0.006 mm per year (95% confidence interval, -0.004 to 0.016) and -0.005 mm per year (95% confidence interval, -0.015 to 0.005) in the aspirin group. There was no statistically significant difference between the groups in the annualized rate of change of common carotid intima-media thickness (0.011 mm per year; 95% confidence interval, -0.003 to 0.025). At 12 months of follow-up, 66% of Terutroban patients had no emergent plaques, 31% had 1 to 2 emergent plaques, and 3% had ≥3 emergent plaques. In the aspirin group, the corresponding percentages were 64%, 32%, and 4%. Over time, there was no statistically significant difference in the number of emergent carotid plaques between treatment modalities (rate ratio, 0.91; 95% confidence interval, 0.77-1.07). CONCLUSIONS Compared with aspirin, Terutroban did not beneficially affect progression of carotid atherosclerosis among well-treated patients with a history of ischemic stroke or transient ischemic attacks with an internal carotid stenosis <70%. CLINICAL TRIAL REGISTRATION URL http://www.controlled-trials.com. Unique identifier: ISRCTN66157730.
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Affiliation(s)
- Michiel L Bots
- From the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (M.L.B.); Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom (I.F., S.M.L.); Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France (S.L.); Department of Neurology and Stroke Center, Hôpital Bichat and INSERM U698, Paris, France (P.J.T.); and Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany (M.G.H.).
| | - Ian Ford
- From the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (M.L.B.); Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom (I.F., S.M.L.); Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France (S.L.); Department of Neurology and Stroke Center, Hôpital Bichat and INSERM U698, Paris, France (P.J.T.); and Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany (M.G.H.)
| | - Suzanne M Lloyd
- From the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (M.L.B.); Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom (I.F., S.M.L.); Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France (S.L.); Department of Neurology and Stroke Center, Hôpital Bichat and INSERM U698, Paris, France (P.J.T.); and Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany (M.G.H.)
| | - Stephane Laurent
- From the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (M.L.B.); Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom (I.F., S.M.L.); Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France (S.L.); Department of Neurology and Stroke Center, Hôpital Bichat and INSERM U698, Paris, France (P.J.T.); and Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany (M.G.H.)
| | - Pierre J Touboul
- From the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (M.L.B.); Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom (I.F., S.M.L.); Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France (S.L.); Department of Neurology and Stroke Center, Hôpital Bichat and INSERM U698, Paris, France (P.J.T.); and Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany (M.G.H.)
| | - Michael G Hennerici
- From the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (M.L.B.); Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom (I.F., S.M.L.); Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France (S.L.); Department of Neurology and Stroke Center, Hôpital Bichat and INSERM U698, Paris, France (P.J.T.); and Department of Neurology, UMM, University of Heidelberg, Mannheim, Germany (M.G.H.)
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Preiss D, Lloyd SM, Ford I, McMurray JJ, Holman RR, Welsh P, Fisher M, Packard CJ, Sattar N. Metformin for non-diabetic patients with coronary heart disease (the CAMERA study): a randomised controlled trial. Lancet Diabetes Endocrinol 2014; 2:116-24. [PMID: 24622715 DOI: 10.1016/s2213-8587(13)70152-9] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Metformin reduces cardiovascular risk in patients with type 2 diabetes seemingly independent of lowering blood glucose concentration. We assessed the cardiovascular effects of metformin in individuals without type 2 diabetes. METHODS We did a single-centre, double-blind, placebo-controlled trial at the Glasgow Clinical Research Facility (Glasgow, UK). We enrolled patients taking statins who did not have type 2 diabetes but who did have coronary heart disease and large waist circumferences. Participants were randomly assigned (1:1) by computer to either metformin (850 mg twice daily) or matching placebo in block sizes of four. Patients, investigators, trial staff, and statisticians were masked to treatment allocation. The primary endpoint was progression of mean distal carotid intima-media thickness (cIMT) over 18 months in the modified intention-to-treat population. Secondary endpoints were changes in carotid plaque score (in six regions), measures of glycaemia (HbA1c, fasting glucose, and insulin concentrations, and Homeostasis Model Assessment of Insulin Resistance [HOMA-IR]), and concentrations of lipids, high sensitivity C-reactive protein, and tissue plasminogen activator. The trial was registered at ClinicalTrials.gov, number NCT00723307. FINDINGS We screened 356 patients, of whom we enrolled 173 (86 in the metformin group, 87 in the placebo group). Average age was 63 years. At baseline, mean cIMT was 0·717 mm (SD 0·129) and mean carotid plaque score was 2·43 (SD 1·55). cIMT progression did not differ significantly between groups (slope difference 0·007 mm per year, 95% CI -0·006 to 0·020; p=0·29). Change of carotid plaque score did not differ significantly between groups (0·01 per year, 95% CI -0·23 to 0·26; p=0·92). Patients taking metformin had lower HbA1c, insulin, HOMA-IR, and tissue plasminogen activator compared with those taking placebo, but there were no significant differences for total cholesterol, HDL-cholesterol, non-HDL-cholesterol, triglycerides, high sensitivity C-reactive protein, or fasting glucose. 138 adverse events occurred in 64 patients in the metformin group versus 120 in 60 patients in the placebo group. Diarrhoea and nausea or vomiting were more common in the metformin group than in the placebo group (28 vs 5). INTERPRETATION Metformin had no effect on cIMT and little or no effect on several surrogate markers of cardiovascular disease in non-diabetic patients with high cardiovascular risk, taking statins. Further evidence is needed before metformin can be recommended for cardiovascular benefit in this population. FUNDING Chief Scientist Office (Scotland).
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Affiliation(s)
- David Preiss
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - John J McMurray
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| | - Paul Welsh
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Miles Fisher
- Department of Diabetes, Glasgow Royal Infirmary, Glasgow, UK
| | - Chris J Packard
- Glasgow Clinical Research Facility, Tennent Building, Western Infirmary, Glasgow, UK
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Sumukadas D, Band M, Miller S, Cvoro V, Witham M, Struthers A, McConnachie A, Lloyd SM, McMurdo M. Do ACE inhibitors improve the response to exercise training in functionally impaired older adults? A randomized controlled trial. J Gerontol A Biol Sci Med Sci 2013; 69:736-43. [PMID: 24201696 PMCID: PMC4022094 DOI: 10.1093/gerona/glt142] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [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] [Indexed: 11/16/2022] Open
Abstract
Background. Loss of muscle mass and strength with ageing is a major cause for falls, disability, and morbidity in older people. Previous studies have found that angiotensin-converting enzyme inhibitors (ACEi) may improve physical function in older people. It is unclear whether ACEi provide additional benefit when added to a standard exercise training program. We examined the effects of ACEi therapy on physical function in older people undergoing exercise training. Methods. Community-dwelling people aged ≥65 years with functional impairment were recruited through general (family) practices. All participants received progressive exercise training. Participants were randomized to receive either 4 mg perindopril or matching placebo daily for 20 weeks. The primary outcome was between-group change in 6-minute walk distance from baseline to 20 weeks. Secondary outcomes included changes in Short Physical Performance Battery, handgrip and quadriceps strength, self-reported quality of life using the EQ-5D, and functional impairment measured using the Functional Limitations Profile. Results. A total of 170 participants (n = 86 perindopril, n = 84 placebo) were randomized. Mean age was 75.7 (standard deviation [SD] 6.8) years. Baseline 6-minute walk distance was 306 m (SD 99). Both groups increased their walk distance (by 29.6 m perindopril, 36.4 m placebo group) at 20 weeks, but there was no statistically significant treatment effect between groups (−8.6m [95% confidence interval: −30.1, 12.9], p = .43). No statistically significant treatment effects were observed between groups for the secondary outcomes. Adverse events leading to withdrawal were few (n = 0 perindopril, n = 4 placebo). Interpretation. ACE inhibitors did not enhance the effect of exercise training on physical function in functionally impaired older people.
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Affiliation(s)
- Deepa Sumukadas
- Division of Cardiovascular and Diabetes Medicine, University of Dundee, UK.
| | - Margaret Band
- Division of Cardiovascular and Diabetes Medicine, University of Dundee, UK
| | | | - Vera Cvoro
- Department of Care of the Elderly, National Health Service Fife, Kirkcaldy, UK
| | - Miles Witham
- Division of Cardiovascular and Diabetes Medicine, University of Dundee, UK
| | - Allan Struthers
- Division of Cardiovascular and Diabetes Medicine, University of Dundee, UK
| | | | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, UK
| | - Marion McMurdo
- Division of Cardiovascular and Diabetes Medicine, University of Dundee, UK
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Lloyd SM, Stott DJ, de Craen AJM, Kearney PM, Sattar N, Perry I, Packard CJ, Briggs A, Marchbank L, Comber H, Jukema JW, Westendorp RGJ, Trompet S, Buckley BM, Ford I. Long-term effects of statin treatment in elderly people: extended follow-up of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). PLoS One 2013; 8:e72642. [PMID: 24023757 PMCID: PMC3759378 DOI: 10.1371/journal.pone.0072642] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 07/12/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The PROspective Study of Pravastatin in the Elderly at Risk (PROSPER), a placebo-controlled trial of pravastatin, demonstrated a 19% reduction in coronary outcomes (p=0.006) after a mean of 3.2 years, with no impact on stroke outcomes or all-cause mortality. However, there was a suggestion of increased cancer risk. Our aim is to determine the long-term benefits and safety of pravastatin treatment in older people using post-trial follow-up of the PROSPER participants. METHODS 5,804 (2,520 Scottish) men and women aged 70-82 years with either pre-existing vascular disease or increased risk of such disease because of smoking, hypertension or diabetes, were randomised to 40 mg pravastatin or matching placebo. Using record linkage to routinely collected health records, all participants (full cohort) were linked to death and cancer registries, and the Scottish cohort additionally to hospital admissions, to provide composite fatal/non-fatal cardiovascular outcomes (total mean follow-up 8.6 years). RESULTS Pravastatin treatment for 3.2 years reduced CHD death in the full cohort, hazard ratio (HR) 0.80, 95% confidence interval (CI) 0.68-0.95, p=0.0091 and fatal coronary events or coronary hospitalisations in the Scottish cohort (HR 0.81, 95% CI 0.69-0.95, p=0.0081) over 8.6 years. There was no reduction in stroke or all-cause mortality. Cancer risk was not increased in the full cohort (HR 1.08, 95% CI 0.96-1.21, p=0.22). CONCLUSIONS Pravastatin treatment of elderly high-risk subjects for 3.2 years provided long-term protection against CHD events and CHD mortality. However, this was not associated with any increase in life expectancy, possibly due to competing mortality with deaths from other causes. There was no evidence of long-term increased risk of cancer. TRIAL REGISTRATION ISRCTN40976937.
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Affiliation(s)
- Suzanne M. Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - David J. Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Anton J. M. de Craen
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Patricia M. Kearney
- Department of Epidemiology and Public Health, University College, Cork, Ireland
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ivan Perry
- Department of Epidemiology and Public Health, University College, Cork, Ireland
| | - Christopher J. Packard
- National Health Service Research and Development Directorate, Greater Glasgow and Clyde Health Board, Glasgow, United Kingdom
| | - Andrew Briggs
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Laura Marchbank
- Information Services Division Scotland, National Health Service (Scotland), Paisley, United Kingdom
| | | | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rudi G. J. Westendorp
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stella Trompet
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Brendan M. Buckley
- Department of Pharmacology and Therapeutics, University College, Cork, Ireland
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
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Abstract
BACKGROUND There has been no large study of ECG measures derived by automated methods in an apparently healthy indigenous West African population. METHODS ECGs were recorded from apparently healthy Nigerians and analysed using automated methods. Age and sex based normal ranges were then established. RESULTS A total of 782 males and 479 females aged between 20 and 87years were studied. Mean QRS duration in males was 87.9±9.4ms and 83.4±7.6ms in females (P<.0001). Mean QTc (Hodges) was 393±16ms in males and 406±16ms in females (P<.0001). The Cornell index (SV3+RaVL) was higher in males and decreased with increasing age in males though the reverse was true in females (P<.0001). STj amplitude was lower in older compared to younger males and higher in males. CONCLUSION This is the first large study of automated ECG measurements from healthy blacks living in West Africa which allows the determination of ECG normal limits in such a population.
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Millar K, Lloyd SM, McLean JS, Batty GD, Burns H, Cavanagh J, Deans KA, Ford I, McConnachie A, McGinty A, Mõttus R, Packard CJ, Sattar N, Shiels PG, Velupillai YN, Tannahill C. Personality, socio-economic status and inflammation: cross-sectional, population-based study. PLoS One 2013; 8:e58256. [PMID: 23516457 PMCID: PMC3596406 DOI: 10.1371/journal.pone.0058256] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 02/05/2013] [Indexed: 12/14/2022] Open
Abstract
Background Associations between socio-economic status (SES), personality and inflammation were examined to determine whether low SES subjects scoring high on neuroticism or hostility might suffer relatively higher levels of inflammation than affluent subjects. Methods In a cross-sectional design, 666 subjects were recruited from areas of high (most deprived – “MD”) and low (least deprived – “LD”) deprivation. IL-6, ICAM-1, CRP and fibrinogen were measured along with demographic and health-behaviour variables, and personality traits of neuroticism, extraversion and psychoticism (hostility). Regression models assessed the prediction of inflammation as a function of personality, deprivation and their interaction. Results Levels of CRP and IL-6 were an increasing function of neuroticism and extraversion only in LD subjects opposite trends were seen in MD subjects. The result was ascribed parsimoniously to an inflammatory ceiling effect or, more speculatively, to SES-related health-behaviour differences. Psychoticism was strongly associated with ICAM-1 in both MD and LD subjects. Conclusions The association between neuroticism, CRP and IL-6 may be reduced in MD subjects confirming speculation that the association differs across population sub-groups. The association between psychoticism and ICAM-1 supports evidence that hostility has adverse effects upon the endothelium, with consequences for cardiovascular health. Health interventions may be more effective by accounting for personality-related effects upon biological processes.
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Affiliation(s)
- Keith Millar
- College of Medical, Veterinary and Life Sciences, Institute of Mental Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Suzanne M. Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | | | - G. David Batty
- MRC Social and Public Health Sciences Unit, Glasgow, Scotland
- Department of Epidemiology and Public Health, University College London, London, England
| | | | - Jonathan Cavanagh
- College of Medical, Veterinary and Life Sciences, Institute of Mental Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Kevin A. Deans
- Department of Vascular Biochemistry, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, Scotland
- Department of Clinical Biochemistry, NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, Scotland
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | - Agnes McGinty
- Glasgow Clinical Research Facility, Tennent Building, Western Infirmary, Glasgow, Scotland
| | - Réne Mõttus
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, Scotland
| | - Chris J. Packard
- Glasgow Clinical Research Facility, Tennent Building, Western Infirmary, Glasgow, Scotland
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | - Paul G. Shiels
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Yoga N. Velupillai
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Abrahamsson P, Swedberg K, Borer JS, Böhm M, Kober L, Komajda M, Lloyd SM, Metra M, Tavazzi L, Ford I. Risk following hospitalization in stable chronic systolic heart failure. Eur J Heart Fail 2013; 15:885-91. [PMID: 23460732 DOI: 10.1093/eurjhf/hft032] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [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: 11/12/2022] Open
Abstract
AIMS We explored the impact of being hospitalized due to worsening heart failure (WHF) or a myocardial infarction (MI) on subsequent mortality in a large contemporary data set of patients with stable chronic systolic heart failure (HF). METHODS AND RESULTS A total of 6558 patients with stable systolic HF, 6505 with analysable data, with an EF of ≤35%, who were included in the Systolic Heart failure treatment with the If inhibitor ivabradine Trial (SHIFT), were followed for a median of 22.9 months with respect to hospitalizations and vital status. Among the 1288 patients who had at least one hospitalization due to WHF or MI, 455 (35.3%) died during follow-up compared with 600 (11.5%) among patients not hospitalized for these reasons. The risk for death was highest in the early phase after hospitalization. The risk declined rapidly during the first month but remained 3.5-fold (95% confidence interval 2.3-5.1) increased at 18 months after a first WHF hospitalization and 8.8-fold (95% confidence interval 3.6-21.6) increased at 18 months after a first MI hospitalization. CONCLUSION The present study confirms previous findings that in patients with stable chronic systolic HF, a hospitalization for WHF or MI is associated with substantially increased risk for subsequent death even with contemporary extensive background pharmacological therapy. The risk is most pronounced in the early phase of hospitalization but remains elevated even after 18 months. Preventing HF hospitalization appears as an important therapeutic objective in such patients, and a hospitalization for WHF or MI should lead to a careful therapeutic reassessment.
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Affiliation(s)
- Putte Abrahamsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.
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Lloyd SM, Babiker M, Yuan J, Kerr-Edwards C. Electromagnetic vortex fields, spin, and spin-orbit interactions in electron vortices. Phys Rev Lett 2012; 109:254801. [PMID: 23368471 DOI: 10.1103/physrevlett.109.254801] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Indexed: 06/01/2023]
Abstract
Electron vortices are shown to possess electric and magnetic fields by virtue of their quantized orbital angular momentum and their charge and current density sources. The spatial distributions of these fields are determined for a Bessel electron vortex. It is shown how these fields lead naturally to interactions involving coupling to the spin magnetic moment and spin-orbit interactions which are absent for ordinary electron beams. The orders of magnitude of the effects are estimated here for ȧngström scale electron vortices generated within a typical electron microscope.
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Affiliation(s)
- S M Lloyd
- Department of Physics, University of York, Heslington, York YO10 5DD, United Kingdom
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28
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Poortvliet RKE, Ford I, Lloyd SM, Sattar N, Mooijaart SP, de Craen AJM, Westendorp RGJ, Jukema JW, Packard CJ, Gussekloo J, de Ruijter W, Stott DJ. Blood pressure variability and cardiovascular risk in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). PLoS One 2012; 7:e52438. [PMID: 23285043 PMCID: PMC3527505 DOI: 10.1371/journal.pone.0052438] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 11/13/2012] [Indexed: 12/26/2022] Open
Abstract
Variability in blood pressure predicts cardiovascular disease in young- and middle-aged subjects, but relevant data for older individuals are sparse. We analysed data from the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study of 5804 participants aged 70–82 years with a history of, or risk factors for cardiovascular disease. Visit-to-visit variability in blood pressure (standard deviation) was determined using a minimum of five measurements over 1 year; an inception cohort of 4819 subjects had subsequent in-trial 3 years follow-up; longer-term follow-up (mean 7.1 years) was available for 1808 subjects. Higher systolic blood pressure variability independently predicted long-term follow-up vascular and total mortality (hazard ratio per 5 mmHg increase in standard deviation of systolic blood pressure = 1.2, 95% confidence interval 1.1–1.4; hazard ratio 1.1, 95% confidence interval 1.1–1.2, respectively). Variability in diastolic blood pressure associated with increased risk for coronary events (hazard ratio 1.5, 95% confidence interval 1.2–1.8 for each 5 mmHg increase), heart failure hospitalisation (hazard ratio 1.4, 95% confidence interval 1.1–1.8) and vascular (hazard ratio 1.4, 95% confidence interval 1.1–1.7) and total mortality (hazard ratio 1.3, 95% confidence interval 1.1–1.5), all in long-term follow-up. Pulse pressure variability was associated with increased stroke risk (hazard ratio 1.2, 95% confidence interval 1.0–1.4 for each 5 mmHg increase), vascular mortality (hazard ratio 1.2, 95% confidence interval 1.0–1.3) and total mortality (hazard ratio 1.1, 95% confidence interval 1.0–1.2), all in long-term follow-up. All associations were independent of respective mean blood pressure levels, age, gender, in-trial treatment group (pravastatin or placebo) and prior vascular disease and cardiovascular disease risk factors. Our observations suggest variability in diastolic blood pressure is more strongly associated with vascular or total mortality than is systolic pressure variability in older high-risk subjects.
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Affiliation(s)
- Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
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Berry C, Lloyd SM, Wang Y, Macdonald A, Ford I. The changing course of aortic valve disease in Scotland: temporal trends in hospitalizations and mortality and prognostic importance of aortic stenosis. Eur Heart J 2012; 34:1538-47. [PMID: 23111418 DOI: 10.1093/eurheartj/ehs339] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS To investigate the contemporary clinical course of aortic valve disease types. METHODS AND RESULTS We performed a retrospective population-level epidemiological study of hospitalized care in Scotland from 1 January 1997 to 31 December 2005 using electronic case identification of hospital admissions and deaths. Time-to-event analyses were performed using Cox Proportional-Hazards models. A total of 19 733 adults with an index hospitalization and a final diagnosis of non-congenital aortic valve disease were identified. Aortic stenosis, aortic insufficiency, mixed aortic valve disease, or unspecified aortic valve disease occurred in 13 220 (67.0%), 2807 (14.2%), 699 (3.5%), and 3007 (15.2%), individuals, respectively. The majority of hospitalizations occurred in elderly persons aged 80 and older. In total, 9981 (50.6%) patients had died by 31 December 2006. When compared with aortic stenosis, the risk of death was less with aortic insufficiency [hazard ratio (95% confidence interval) 0.79 (0.74, 0.84)] and mixed aortic valve disease [0.83 (0.74, 0.93)]. Female gender, admission year, and hypertension were associated with lower mortality in patients with aortic stenosis. Patients with aortic stenosis had increased risk of death or heart failure (adjusted P < 0.001). Of all, 3673 (19.4%) patients had a first aortic valve replacement of whom 73.2% had aortic stenosis, 11.9% aortic valve disease (unspecified),10.0% aortic insufficiency, and 4.9% aortic stenosis with insufficiency. Patients with aortic stenosis with insufficiency had increased likelihood of aortic valve replacement [1.19 (1.02, 1.38)]. Age, female gender, and co-morbidity reduced the likelihood of aortic valve replacement. CONCLUSION The incidence of aortic valve stenosis has substantially increased in Scotland in recent years. Aortic stenosis predicts morbidity and mortality when compared with other types of aortic valve disease.
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Affiliation(s)
- Colin Berry
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK.
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Bucknall CE, Miller G, Lloyd SM, Cleland J, McCluskey S, Cotton M, Stevenson RD, Cotton P, McConnachie A. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ 2012; 344:e1060. [PMID: 22395923 PMCID: PMC3295724 DOI: 10.1136/bmj.e1060] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2011] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether supported self management in chronic obstructive pulmonary disease (COPD) can reduce hospital readmissions in the United Kingdom. DESIGN Randomised controlled trial. SETTING Community based intervention in the west of Scotland. PARTICIPANTS Patients admitted to hospital with acute exacerbation of COPD. INTERVENTION Participants in the intervention group were trained to detect and treat exacerbations promptly, with ongoing support for 12 months. MAIN OUTCOME MEASURES The primary outcome was hospital readmissions and deaths due to COPD assessed by record linkage of Scottish Morbidity Records; health related quality of life measures were secondary outcomes. RESULTS 464 patients were randomised, stratified by age, sex, per cent predicted forced expiratory volume in 1 second, recent pulmonary rehabilitation attendance, smoking status, deprivation category of area of residence, and previous COPD admissions. No difference was found in COPD admissions or death (111/232 (48%) v 108/232 (47%); hazard ratio 1.05, 95% confidence interval 0.80 to 1.38). Return of health related quality of life questionnaires was poor (n=265; 57%), so that no useful conclusions could be made from these data. Pre-planned subgroup analysis showed no differential benefit in the primary outcome relating to disease severity or demographic variables. In an exploratory analysis, 42% (75/150) of patients in the intervention group were classified as successful self managers at study exit, from review of appropriateness of use of self management therapy. Predictors of successful self management on stepwise regression were younger age (P=0.012) and living with others (P=0.010). COPD readmissions/deaths were reduced in successful self managers compared with unsuccessful self managers (20/75 (27%) v 51/105 (49%); hazard ratio 0.44, 0.25 to 0.76; P=0.003). CONCLUSION Supported self management had no effect on time to first readmission or death with COPD. Exploratory subgroup analysis identified a minority of participants who learnt to self manage; this group had a significantly reduced risk of COPD readmission, were younger, and were more likely to be living with others. TRIAL REGISTRATION Clinical trials NCT 00706303.
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Affiliation(s)
- C E Bucknall
- Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow G4 0SF, UK.
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Longmate AG, Ellis KS, Boyle L, Maher S, Cairns CJS, Lloyd SM, Lang C. Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. BMJ Qual Saf 2011; 20:174-80. [PMID: 21303772 DOI: 10.1136/bmjqs.2009.037200] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Central-venous-catheter (CVC)-related bloodstream infection (CRBSI) is a complication of intensive care stay which can have important adverse consequences for both patient and institution. There are a number of evidence-based interventions that reduce CRBSI, but it is recognised that consistently applying the best evidence every time is a challenge. METHODS The authors set out to reduce CRBSI and introduced interventions in our intensive care unit (ICU) over a 4-year period using a quality improvement approach. In a setting supportive to change and improvement, the authors established infection surveillance and introduced bundles of care processes relating to insertion and maintenance of CVCs. The changes were supported by educational interventions. The authors measured care processes and outcomes, and used statistical process control charts to illustrate changes. The final 18 months of the work was performed in the context of a national safety improvement programme (The Scottish Patient Safety Programme). RESULTS Following interventions, the annual CRBSI rate fell from 3.4 to 0/1000 patient days with zero episodes during the final 19 months of the study. CONCLUSIONS The authors describe a significant reduction in CRBSI for the first time in a UK ICU. The authors summarised and simplified what to do, measured and provided feedback on outcomes, and improved expectations of performance standards for care processes. The authors believe that these approaches are worthy of serious consideration elsewhere.
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Affiliation(s)
- Andrew G Longmate
- Intensive Care Unit, Stirling Royal Infirmary, NHS Forth Valley, Stirling FK8 2AU, UK.
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Braganza G, Chaudhuri R, McSharry C, Weir CJ, Donnelly I, Jolly L, Lafferty J, Lloyd SM, Spears M, Mair F, Thomson NC. Effects of short-term treatment with atorvastatin in smokers with asthma--a randomized controlled trial. BMC Pulm Med 2011; 11:16. [PMID: 21473764 PMCID: PMC3087704 DOI: 10.1186/1471-2466-11-16] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 04/07/2011] [Indexed: 12/13/2022] Open
Abstract
Background The immune modulating properties of statins may benefit smokers with asthma. We tested the hypothesis that short-term treatment with atorvastatin improves lung function or indices of asthma control in smokers with asthma. Methods Seventy one smokers with mild to moderate asthma were recruited to a randomized double-blind parallel group trial comparing treatment with atorvastatin (40 mg per day) versus placebo for 4 weeks. After 4 weeks treatment inhaled beclometasone (400 μg per day) was added to both treatment arms for a further 4 weeks. The primary outcome was morning peak expiratory flow after 4 weeks treatment. Secondary outcome measures included indices of asthma control and airway inflammation. Results At 4 weeks, there was no improvement in the atorvastatin group compared to the placebo group in morning peak expiratory flow [-10.67 L/min, 95% CI -38.70 to 17.37, p = 0.449], but there was an improvement with atorvastatin in asthma quality of life score [0.52, 95% CI 0.17 to 0.87 p = 0.005]. There was no significant improvement with atorvastatin and inhaled beclometasone compared to inhaled beclometasone alone in outcome measures at 8 weeks. Conclusions Short-term treatment with atorvastatin does not alter lung function but may improve asthma quality of life in smokers with mild to moderate asthma. Trial Registration Clinicaltrials.gov identifier: NCT00463827
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Affiliation(s)
- Georgina Braganza
- Respiratory Medicine, Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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Moug SJ, McColl G, Lloyd SM, Wilson G, Saldanha JD, Diament RH. Comparison of positive lymph node ratio with an inflammation-based prognostic score in colorectal cancer. Br J Surg 2011; 98:282-6. [PMID: 20976703 DOI: 10.1002/bjs.7294] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Two prognostic scoring systems have been proposed in colorectal cancer: the pathologically based positive lymph node ratio (pLNR) and the inflammation-based modified Glasgow Prognostic Score (mGPS). This study compared these two scores with the tumour node metastasis (TNM) staging system in terms of cancer survival. METHODS Between 2003 and 2005, 206 patients, of mean(s.d.) age 69·9(10·6) (range 40-95) years, underwent curative resection for colorectal cancer in two centres. Age, sex, primary tumour site and whether radio/chemotherapy was given were recorded in addition to the three scores (TNM stage, pLNR and mGPS). Univariable and multivariable analyses of overall survival were performed. RESULTS Age, rectal cancer, TNM stage, pLNR and mGPS were significant factors in univariable analysis. On multivariable analysis, N category and tumour stage (I-III) were removed from the model, leaving pLNR and mGPS as independent predictors of overall survival: hazard ratio 1·51 (95 per cent confidence interval 1·24 to 1·84; P < 0·001) and 1·56 (1·18 to 2·08; P = 0·020) respectively. C-statistic analysis, used to compare pLNR and mGPS directly, found only pLNR to be significant (P < 0·001) CONCLUSION This study found pLNR to be the superior prognostic scoring system in determining long-term survival in patients undergoing resection for colorectal cancer.
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Affiliation(s)
- S J Moug
- Department of General Surgery, Crosshouse Hospital, Kilmarnock Road, Kilmarnock KA2 0BE, UK
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Elliott HL, Lloyd SM, Ford I, Meredith PA. Improving blood pressure control in patients with diabetes mellitus and high cardiovascular risk. Int J Hypertens 2011; 2010:490769. [PMID: 21274458 PMCID: PMC3025388 DOI: 10.4061/2010/490769] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 11/02/2010] [Accepted: 11/29/2010] [Indexed: 01/13/2023] Open
Abstract
Patients with diabetes mellitus and symptomatic coronary artery disease are also likely to be hypertensive and, overall, are at very high cardiovascular (CV) risk. This paper reports the findings of a posthoc analysis of the 1113 patients with diabetes mellitus in the ACTION trial: ACTION itself showed that outcomes in patients with stable angina and hypertension were significantly improved when a long-acting calcium channel blocking drug (nifedipine GITS) was added to their treatment regimens. This further analysis of the ACTION database in those patients with diabetes has identified a number of practical therapeutic issues which are still relevant because of potential outcome benefits, particularly in relation to BP control. For example, despite background CV treatment and, specifically, despite the widespread use of ACE Inhibitor drugs, the addition of nifedipine GITS was associated with significant benefits: improvement in BP control by an average of 6/3 mmHg and significant improvements in outcome. In summary, this retrospective analysis has identified that the addition of nifedipine GITS resulted in improved BP control and significant outcome benefits in patients with diabetes who were at high CV risk. There is evidence to suggest that these findings are of direct relevance to current therapeutic practice.
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Affiliation(s)
- Henry L Elliott
- Institute of Pharmaceutical and Biomedical Sciences, University of Strathclyde, Glasgow G1 1XQ, UK
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Abstract
Prophylactic bilateral mastectomy represents a new and controversial cancer prevention strategy for women at high-risk of familial breast cancer, the psychosocial implications of which are yet to be fully explored. A qualitative methodology was therefore adopted to provide a discovery-orientated study of the perspectives of ten women who had undergone prophylactic mastectomy and the views of eight of their partners. Each participant was interviewed with the aim of exploring the personal experiences of surgery, factors associated with psychological adjustment and the impact on the family. Data were transcribed and systematically analysed using Grounded Theory. Themes emerging from participants' accounts formed seven significant categories that represented women's key experiences: (i) deciding; (ii) telling; (iii) experiencing surgery and recovering; (iv) maintaining womanliness; (v) processing the loss; and (vi) moving on. The importance of the social context in women's experience and difficulties of isolation/eliciting support were also highlighted: (vii) isolation and being supported. A core category of 'Suffering and countering multiple loss' considered central to women's experience, integrated the seven significant categories and provided further conceptualisation of women's experience. Implications for clinical practice are highlighted.
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Affiliation(s)
- S M Lloyd
- School of Health Policy and Practice, University of East Anglia, Norwich, UK
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Abstract
Fourty patients undergoing total hip replacement under spinal anaesthesia were allocated randomly to have a thigh tourniquet inflated after exanguination of the leg not being operated on or to act as controls. Significant hypotension (systolic arterial pressure < 70 mm Hg) was treated with i.v. ephedrine in 6 mg boluses. There was no significant difference between the two groups with respect to systolic blood pressure or requirement of ephedrine, during the hour that the tourniquet was applied or the period immediately after the removal of the tourniquet.
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Affiliation(s)
- S M Lloyd
- Department of Anaesthesia, Western Infirmary, Glasgow, UK
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Gould TH, Crosby DL, Harmer M, Lloyd SM, Lunn JN, Rees GA, Roberts DE, Webster JA. Policy for controlling pain after surgery: effect of sequential changes in management. BMJ 1992; 305:1187-93. [PMID: 1467721 PMCID: PMC1883782 DOI: 10.1136/bmj.305.6863.1187] [Citation(s) in RCA: 191] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To observe the effects of introducing an acute pain service to the general surgical wards of a large teaching hospital. DESIGN A study in seven stages: (1) an audit of current hospital practice succeeded by the sequential introduction to the general surgical wards of (2) pain assessment charts; (3) an algorithm to allow more frequent use of intramuscular analgesia; (4) increased use of local anaesthetic techniques of wound infiltration and nerve blocks; (5) an information sheet for patients about postoperative pain; (6) the introduction of patient controlled analgesia; (7) a repeat audit of hospital practice. Data were collected on each patient 24 hours after operation. SETTING University Hospital of Wales, which has both district general and tertiary referral functions. PATIENTS 2035 patients over nine months from all surgical specialties (excluding cardiac) at the hospital. General surgical operations were studied in detail and separated into major, intermediate, and minor for data collection. MAIN OUTCOME MEASURES A change in the median visual analogue pain scores 24 hours after surgery for pain during relaxation, pain on movement, and pain on deep inspiration at each stage of the study. RESULTS There was a reduction in median visual analogue scores during the study. The median (95% confidence interval) scores for pain during relaxation decreased from 45 (34 to 53) in stage 1 to 16 (10 to 20) in stage 7 for major surgical procedures. Pain on movement decreased from 78 (66 to 80) to 46 (38 to 48), and pain on deep inspiration decreased from 64 (48 to 78) to 36 (31 to 38). The reductions in median scores for intermediate and minor operative procedures showed similar patterns. CONCLUSIONS The introduction of an acute pain service to the general surgical wards led to considerable improvement in the level of postoperative pain as assessed by visual analogue scores. Simple techniques of regular pain assessment and the more frequent use of intramuscular analgesia as a result of using an algorithm were particularly effective.
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Affiliation(s)
- T H Gould
- Department of Anaesthetics, University Hospital of Wales
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Abstract
Over a 2-year period, 31 patients underwent prolonged hydrostatic bladder distension for benign and malignant bladder disease in this unit. Of these, 29 patients had benign functional disorders or bladder contracture, and in 2 patients hydrodistension was performed for complications of treatment for bladder neoplasia. Of the 29 patients with benign disease, 6 observed marked improvement and 8 some improvement in their symptoms, and 12 received no benefit. Patients with detrusor hypersensitivity fared better than those with detrusor instability or interstitial cystitis. A patient with malignant bladder disease died soon after the procedure as a result of a myocardial infarction. Problems attributed to the hydrostatic balloon catheter were responsible for 2 failures. The regional anaesthetic technique failed to provide adequate anaesthesia for hydrodistension in 9 procedures and limited the duration to 2 h in 13 others. Following recall of the perished balloon catheters by the manufacturer, and the introduction of continuous spinal anaesthesia, the number of technical failures has been reduced. This technique still has an important role to play in the relief of severe symptoms unresponsive to medical treatment, but it is important that ideal conditions are provided for hydrodistension in order to ensure maximum success, particularly when the alternative is major surgery.
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Affiliation(s)
- S N Lloyd
- Department of Urology, Western Infirmary, Glasgow
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Lloyd SM, Miller RL. Black student enrollment in US medical schools. JAMA 1989; 261:272-4. [PMID: 2909025] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Blacks represent about 12% of the nation's population, but only 6% of the total medical school enrollment, 5% of medical school graduates, 5% of postgraduate trainees, 3% of physicians in practice, and 2% of medical school faculties. Addressing this underrepresentation of blacks in medicine not only is a matter of justice, equity, and national conscience but also has implications for the provision of quality physician care to this nation's minority and medically underserved populations. Black physicians are more likely to understand the cultural and social context of illness and disability among blacks and are also more likely to be able to communicate effectively with black patients. Black physicians are also more likely to practice in communities whose residents lack adequate access to medical care. An approach to addressing the problem of underrepresentation is proposed, consisting of activities at the precollege, college, and medical school levels.
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Affiliation(s)
- S M Lloyd
- College of Medicine, Howard University, Washington, DC 20059
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Lloyd SM, Elkins BS. Subscriber suits: how to avoid them. Health Care Strateg Manage 1986; 4:12-6. [PMID: 10275403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
As HMOs and PROs become more significant elements of the health delivery system, they also become more likely targets for lawsuits. This article identifies twelve major liability risks of these organizations as well as those who provide services to HMOs and PPOs. Also presented are steps that can be taken to help protect against those risks.
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Lloyd SM, Johnson DG. Practice patterns of black physicians: results of a survey of Howard University College of Medicine alumni. J Natl Med Assoc 1982; 74:129-41. [PMID: 7120450 PMCID: PMC2552837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Over 600 Howard University medical alumni of seven representative classes graduating from 1955 to 1975 were surveyed by questionnaire in 1975 and 1976. Replies of the 252 black respondents confirm that these graduates are providing substantial care to blacks, the economically disadvantaged, and residents of the inner city. Survey findings reaffirm the necessity to train more black physicians and to provide data on current and future practice patterns. Comparisons are made between the practice patterns of earlier (1955 to 1970) and later (1973 to 1975) black graduates. A general bibliography of publications relevant to the practice patterns of black physicians is included.
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Secundy MG, Lloyd SM. Clinical experiences for freshmen and sophomore medical students. An educational innovation. J Natl Med Assoc 1974; 66:87-8, 7. [PMID: 4461841 PMCID: PMC2609123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Lloyd SM, Ullrich OA. The Progress of Pupils in an Ungraded Class. Psychol Clin 1918; 11:276-287. [PMID: 28909780 PMCID: PMC5145035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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