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Tzortziou Brown V, McCartney M, Heneghan C. Authors' reply to Caesar and colleagues, Thornton, Kemple, and Singh. BMJ 2020; 371:m4036. [PMID: 33082126 DOI: 10.1136/bmj.m4036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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McCartney M, Sullivan F, Heneghan C. Information and rational decision-making: explanations to patients and citizens about personal risk of COVID-19. BMJ Evid Based Med 2020; 26:bmjebm-2020-111541. [PMID: 33077575 DOI: 10.1136/bmjebm-2020-111541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2020] [Indexed: 01/16/2023]
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Soliman RM, Elhaddad A, Oke J, Eweida W, Sidhom I, Ahmed S, Abdelrahman H, Moussa E, Fawzy M, Zamzam M, Zekri W, Hafez H, Sedky M, Abdalla A, Hammad M, Elzomor H, Ahmed S, Awad M, Abdelhameed S, Mohsen E, Shalaby L, Fouad H, Tarek N, Abouelnaga S, Heneghan C. Temporal trends in childhood cancer survival in Egypt, 2007 to 2017: A large retrospective study of 14 808 children with cancer from the Children's Cancer Hospital Egypt. Int J Cancer 2020; 148:1562-1574. [PMID: 32997796 DOI: 10.1002/ijc.33321] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/24/2020] [Accepted: 09/08/2020] [Indexed: 12/28/2022]
Abstract
Childhood cancer is a priority in Egypt due to large numbers of children with cancer, suboptimal care and insufficient resources. It is difficult to evaluate progress in survival because of paucity of data in National Cancer Registry. In this study, we studied survival rates and trends in survival of the largest available cohort of children with cancer (n = 15 779, aged 0-18 years) from Egypt between 2007 and 2017, treated at Children's Cancer Hospital Egypt-(CCHE), representing 40% to 50% of all childhood cancers across Egypt. We estimated 5-year overall survival (OS) for 14 808 eligible patients using Kaplan-Meier method, and determined survival trends using Cox regression by single year of diagnosis and by diagnosis periods. We compared age-standardized rates to international benchmarks in England and the United States, identified cancers with inferior survival and provided recommendations for improvement. Five-year OS was 72.1% (95% CI 71.3-72.9) for all cancers combined, and survival trends increased significantly by single year of diagnosis (P < .001) and by calendar periods from 69.6% to 74.2% (P < .0001) between 2007-2012 and 2013-2017. Survival trends improved significantly for leukemias, lymphomas, CNS tumors, neuroblastoma, hepatoblastoma and Ewing Sarcoma. Survival was significantly lower by 9% and 11.2% (P < .001) than England and the United States, respectively. Significantly inferior survival was observed for the majority of cancers. Although survival trends are improving for childhood cancers in Egypt/CCHE, survival is still inferior in high-income countries. We provide evidence-based recommendations to improve survival in Egypt by reflecting on current obstacles in care, with further implications on practice and policy.
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Smith JA, Abhari RE, Hussain Z, Heneghan C, Collins GS, Carr AJ. Industry ties and evidence in public comments on the FDA framework for modifications to artificial intelligence/machine learning-based medical devices: a cross sectional study. BMJ Open 2020; 10:e039969. [PMID: 33055121 PMCID: PMC7559037 DOI: 10.1136/bmjopen-2020-039969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To determine the extent and disclosure of financial ties to industry and use of scientific evidence in comments on a US Food and Drug Administration (FDA) regulatory framework for modifications to artificial intelligence/machine learning (AI/ML)-based software as a medical device (SaMD). DESIGN Cross-sectional study. SETTING We searched all publicly available comments on the FDA 'Proposed Regulatory Framework for Modifications to Artificial Intelligence/Machine Learning (AI/ML)-Based Software as a Medical Device (SaMD)-Discussion Paper and Request for Feedback' from 2 April 2019 to 8 August 2019. MAIN OUTCOME MEASURES The proportion of articles submitted by parties with financial ties to industry, disclosing those ties, citing scientific articles, citing systematic reviews and meta-analyses, and using a systematic process to identify relevant literature. RESULTS We analysed 125 comments submitted on the proposed framework. 79 (63%) comments came from parties with financial ties; for 36 (29%) comments, it was not clear and the absence of financial ties could only be confirmed for 10 (8%) comments. No financial ties were disclosed in any of the comments that were not from industry submitters. The vast majority of submitted comments (86%) did not cite any scientific literature, just 4% cited a systematic review or meta-analysis and no comments indicated that a systematic process was used to identify relevant literature. CONCLUSIONS Financial ties to industry were common and undisclosed, and scientific evidence, including systematic reviews and meta-analyses, were rarely cited. To ensure regulatory frameworks best serve patient interests, the FDA should mandate disclosure of potential conflicts of interest (including financial ties) in comments, encourage the use of scientific evidence, and encourage engagement from non-conflicted parties.
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Doshi P, Jefferson T, Jones M, Heneghan C. Contradictory Findings on Efficacy of Neuraminidase Inhibitors Not Cited. J Infect Dis 2020; 222:1578-1579. [DOI: 10.1093/infdis/jiaa199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/20/2020] [Indexed: 11/13/2022] Open
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Heneghan C, Aronson J. Extending anticoagulation treatment for unprovoked venous thromboembolism. BMJ Evid Based Med 2020; 25:184-186. [PMID: 31771946 DOI: 10.1136/bmjebm-2019-111252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 11/03/2022]
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Tzortziou Brown V, McCartney M, Heneghan C. Appraisal and revalidation for UK doctors—time to assess the evidence. BRITISH MEDICAL JOURNAL 2020. [DOI: 10.1136/bmj.m3415] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Sheppard JP, Lown M, Burt J, Temple E, Lowe R, Ashby H, Todd O, Allen J, Ford GA, Fraser R, Heneghan C, Hobbs FR, Jowett S, Little P, Mant J, Mollison J, Payne R, Williams M, Yu L, McManus RJ. Generalizability of Blood Pressure Lowering Trials to Older Patients: Cross‐Sectional Analysis. J Am Geriatr Soc 2020; 68:2508-2515. [DOI: 10.1111/jgs.16749] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/17/2022]
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Mahtani KR, Heneghan C, Aronson J. Single screening or double screening for study selection in systematic reviews? BMJ Evid Based Med 2020; 25:149-150. [PMID: 31722997 DOI: 10.1136/bmjebm-2019-111269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2019] [Indexed: 11/04/2022]
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Muthee TB, Kimathi D, Richards GC, Etyang A, Nunan D, Williams V, Heneghan C. Factors influencing the implementation of cardiovascular risk scoring in primary care: a mixed-method systematic review. Implement Sci 2020; 15:57. [PMID: 32690051 PMCID: PMC7370418 DOI: 10.1186/s13012-020-01022-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/08/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) such as ischemic heart disease and stroke is the leading causes of death and disability globally with a growing burden in low and middle-income countries. A credible way of managing the incidence and prevalence of cardiovascular diseases is by reducing risk factors. This understanding has led to the development and recommendation for the clinical use of cardiovascular risk stratification tools. These tools enhance clinical decision-making. However, there is a lag in the implementation of these tools in most countries. This systematic review seeks to synthesise the current knowledge of the factors influencing the implementation of cardiovascular risk scoring in primary care settings. METHODS We searched bibliographic databases and grey literature for studies of any design relating to the topic. Titles, abstracts and full texts were independently assessed for eligibility by two reviewers. This was followed by quality assessment and data extraction. We analysed data using an integrated and best fit framework synthesis approach to identify these factors. Quantitative and qualitative forms of data were combined into a single mixed-methods synthesis. The Consolidated Framework for Implementation Research was used as the guiding tool and template for this analysis. RESULTS Twenty-five studies (cross-sectional n = 12, qualitative n = 9 and mixed-methods n = 4) were included in this review. Twenty (80%) of these were conducted in high-income countries. Only four studies (16%) included patients as participants. This review reports on a total of eleven cardiovascular risk stratification tools. The factors influencing the implementation of cardiovascular risk scoring are related to clinical setting and healthcare system (resources, priorities, practice culture and organisation), users (attributes and interactions between users) and the specific cardiovascular risk tool (characteristics, perceived role and effectiveness). CONCLUSIONS While these findings bolster the understanding of implementation complexity, there exists limited research in the context of low and middle-income countries. Notwithstanding the need to direct resources in bridging this gap, it is also crucial that these efforts are in concert with providing high-quality evidence on the clinical effectiveness of using cardiovascular risk scoring to improve cardiovascular disease outcomes of mortality and morbidity. TRIAL REGISTRATION PROSPERO registration number: CRD42018092679.
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Boudreault S, Chen J, Wu KY, Plüddemann A, Heneghan C. Self-management programmes for cirrhosis: A systematic review. J Clin Nurs 2020; 29:3625-3637. [PMID: 32671877 DOI: 10.1111/jocn.15416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 06/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Liver cirrhosis severely decreases patients' quality of life. Since self-management programmes have improved quality of life and reduce hospital admissions in other chronic diseases, they have been suggested to decrease liver cirrhosis burden. METHODS We performed a systematic review and meta-analysis to evaluate the clinical impact of self-management programmes in patients with liver cirrhosis, which followed the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes include health-related quality of life (HRQOL) and hospitalisation. We searched MEDLINE, CENTRAL, Embase, CINAHL, PsycINFO and two trial registers to July 2017. RESULTS We identified four randomised trials (299 patients) all rated at a high risk of bias. No difference was demonstrated for HRQOL (standardised mean difference -0.01, 95% CI: -0.48 to 0.46) and hospitalisation days (incidence rate ratio 1.6, 95% CI: 0.5-4.8). For secondary outcomes, one study found a statistically significant improvement in patient knowledge (mean difference (MD) 3.68, 95% CI: 2.11-5.25) while another study found an increase in model for end-stage liver disease scores (MD 2.8, 95% CI: 0.6-4.9) in the self-management group. No statistical difference was found for the other secondary outcomes (self-efficacy, psychological health outcomes, healthcare utilisation, mortality). Overall, the quality of the evidence was low. The content of self-management programmes varied across studies with little overlap. CONCLUSIONS The current literature indicates that there is no evidence of a benefit of self-management programmes for people with cirrhosis. RELEVANCE TO CLINICAL PRACTICE Practitioners should use self-management programmes with caution when delivering care to patients living with cirrhosis. Further research is required to determine what are the key features in a complex intervention like self-management. This review offers a preliminary framework for clinicians to develop a new self-management programme with key features of effective self-management interventions from established models.
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Abstract
In the first of a new evidence column, Rachel Dean and Carl Heneghan argue that while evidence-based veterinary medicine is not perfect we need to stop grumbling about the shortcomings and get on with it in practice.
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Sheppard JP, Burt J, Lown M, Temple E, Lowe R, Fraser R, Allen J, Ford GA, Heneghan C, Hobbs FDR, Jowett S, Kodabuckus S, Little P, Mant J, Mollison J, Payne RA, Williams M, Yu LM, McManus RJ. Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial. JAMA 2020; 323:2039-2051. [PMID: 32453368 PMCID: PMC7251449 DOI: 10.1001/jama.2020.4871] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms. OBJECTIVE This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up. DESIGN, SETTING, AND PARTICIPANTS The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019. INTERVENTIONS Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n = 282) or usual care (control, n = 287), in which no medication changes were mandated. MAIN OUTCOMES AND MEASURES The primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events. RESULTS Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]). CONCLUSIONS AND RELEVANCE Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes. TRIAL REGISTRATION EudraCT Identifier: 2016-004236-38; ISRCTN identifier: 97503221.
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Fitzmaurice D, Fletcher K, Greenfield S, Jowett S, Ward A, Heneghan C, Knight E, Gardiner C, Roalfe A, Sun Y, Hardy P, McCahon D, Heritage G, Shackleford H, Hobbs FDR. Prevention and treatment of venous thromboembolism in hospital and the community: a research programme including the ExACT RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2020. [DOI: 10.3310/pgfar08050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background
Deep-vein thrombosis and pulmonary embolism, collectively known as venous thromboembolism when clots are formed in the venous circulation, are common disorders that are often unprovoked (i.e. there is no obvious reason for the clot occurring). Some people, after having an unprovoked clot, are at a high risk of developing another, or at risk of developing a secondary clot, most importantly in the lungs. Furthermore, in the long term, some patients will develop circulation problems known as post-thrombotic syndrome. The aim of this programme was to improve the understanding of both the prevention and the treatment of thrombosis in people at the highest risk of recurrence.
Objectives
To clarify if it is possible to identify those people at the highest risk of having a recurrent venous thromboembolism, and if it is possible to prevent this happening by giving anticoagulation treatment for longer. To clarify if it is possible to identify those people at the highest risk of developing post-thrombotic syndrome. To document the current knowledge level about prevention and treatment of venous thromboembolism. To find what the barriers are to implementing measures to prevent venous thromboembolism. To find the most cost-effective means of treating venous thromboembolism.
Design
Mixed methods, comprising a randomised controlled trial, qualitative studies, cost-effectiveness analyses and questionnaire studies, including patient preferences.
Setting
UK general practices and hospitals, predominantly from the Midlands and Shropshire.
Participants
Adults attending participating anticoagulation clinics with a diagnosis of first unprovoked deep-vein thrombosis or pulmonary embolism, and health-care professionals, patients and other stakeholders who were involved in the prevention and treatment of venous thromboembolism.
Intervention
Extended treatment with oral anticoagulation therapy (2 years) versus standard care (treatment with oral anticoagulation therapy for at least 3 months).
Results
Work package 1 demonstrated that extended anticoagulation for up to 2 years was clinically effective and cost-effective in reducing the incidence of recurrent venous thromboembolism, with a small increase in the risk of bleeding. There was no difference in post-thrombotic syndrome incidence or severity, or quality of life, between those undergoing the extended treatment and those receiving the standard care. Work package 2 identified five common themes with regard to the prevention of hospital-acquired thrombosis: communication, knowledge, role of primary care, education and training, and barriers to patient adherence. Work package 3 suggested that extended anticoagulation with novel oral anticoagulants was cost-effective only at the £20,000-per-quality-adjusted life-year level for a recurrence rate of between 17.5% and 22.5%, depending on drug acquisition costs, while identifying a strong patient preference for extended anticoagulation based on a fear of recurrent venous thromboembolism.
Limitations
The major limitation was the failure to reach the planned recruitment target for work package 1.
Conclusions
Extended anticoagulation with warfarin for a first unprovoked venous thromboembolism is clinically effective and cost-effective and is strongly preferred by patients to the alternative of not having treatment. There are significant barriers to the implementation of preventative measures for hospital-acquired thrombosis. Further research is required on identifying patients in whom it is safe to discontinue anticoagulation, and at what time point following a first unprovoked venous thromboembolism this should be done.
Trial registration
Current Controlled Trials ISRCTN73819751 and EudraCT 2101-022119-20.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 5. See the NIHR Journals Library website for further project information.
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Nunan D, Jackson R, Heneghan C. What next for education in evidence-based healthcare? A call for submissions. BMJ Evid Based Med 2020; 25:1-2. [PMID: 31727639 DOI: 10.1136/bmjebm-2019-111301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 11/03/2022]
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Heneghan C, Mahtani KR. Multidisciplinary teams effect on major amputations in patients with diabetes. BMJ Evid Based Med 2020; 26:bmjebm-2020-111342. [PMID: 32234711 DOI: 10.1136/bmjebm-2020-111342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 11/03/2022]
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Aronson JK, Heneghan C, Ferner RE. Medical Devices: Definition, Classification, and Regulatory Implications. Drug Saf 2020; 43:83-93. [PMID: 31845212 DOI: 10.1007/s40264-019-00878-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We propose the following definition of a medical device: "A contrivance designed and manufactured for use in healthcare, and not solely medicinal or nutritional." Current regulatory classifications of medical devices are complex and designed primarily for regulators. We propose a simpler classification, based on (1) the site of application of the device, (2) the time scale of its use, and (3) whether it has an external power source. The regulation of medical devices is less well developed than the regulation of medicinal products, which it could follow more closely. In particular, devices that incorporate medicines should be required to meet the same regulatory standards as medicinal products. This would remove the anomaly that some delivery systems that incorporate medicines are classified as devices while other similar systems that deliver the same medicines are classified as medicinal products. Some improvements might also result from more widespread use of registries, such as those used for prosthetic joint replacements. Registries would allow both a prospective examination of the performance of high-risk devices and a retrospective analysis when signals from other sources of information suggest problems. Those who apply for a marketing authorization for a new device should have to assure regulators of its quality of manufacture, safety, and efficacy before licensing. Even the most straightforward device should be shown to be useable in practice. Trials on patients, or at least simulations of use in the real world, should be practicable for most devices.
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Sheppard JP, Tucker KL, Davison WJ, Stevens R, Aekplakorn W, Bosworth HB, Bove A, Earle K, Godwin M, Green BB, Hebert P, Heneghan C, Hill N, Hobbs FDR, Kantola I, Kerry SM, Leiva A, Magid DJ, Mant J, Margolis KL, McKinstry B, McLaughlin MA, McNamara K, Omboni S, Ogedegbe O, Parati G, Varis J, Verberk WJ, Wakefield BJ, McManus RJ. Self-monitoring of Blood Pressure in Patients With Hypertension-Related Multi-morbidity: Systematic Review and Individual Patient Data Meta-analysis. Am J Hypertens 2020; 33:243-251. [PMID: 31730171 PMCID: PMC7162426 DOI: 10.1093/ajh/hpz182] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease. CONCLUSIONS Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.
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Chughtai B, Mao J, Asfaw TS, Heneghan C, Rardin CR, Sedrakyan A. Long-term Device Outcomes of Mesh Implants in Pelvic Organ Prolapse Repairs. Obstet Gynecol 2020; 135:591-598. [DOI: 10.1097/aog.0000000000003689] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heneghan C, Aronson JK. Why reports of clinical trials should include updated meta-analyses. BMJ Evid Based Med 2020; 25:1-2. [PMID: 31473599 DOI: 10.1136/bmjebm-2019-111243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2019] [Indexed: 12/19/2022]
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Gbinigie O, Allen J, Boylan AM, Hay A, Heneghan C, Moore M, Williams N, Butler C. Does cranberry extract reduce antibiotic use for symptoms of acute uncomplicated urinary tract infections (CUTI)? Protocol for a feasibility study. Trials 2019; 20:767. [PMID: 31870413 PMCID: PMC6929469 DOI: 10.1186/s13063-019-3860-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/28/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Consultations in primary care for symptoms of urinary tract infections (UTIs) are common and patients are frequently treated with antibiotics. Given increasing antimicrobial resistance, there has been interest in non-antibiotic treatment options for common infections. One such option is the use of cranberry extract to treat symptoms attributable to UTIs. METHODS A target of 45 women consulting in primary care, with symptoms suggestive of an uncomplicated UTI for whom the practitioner would normally prescribe antibiotics, will be randomised to receive one of three treatment approaches: (1) immediate prescription for antibiotics; (2) immediate prescription for antibiotics plus a 7-day course of cranberry capsules and (3) cranberry capsules plus a delayed prescription for antibiotics to be used in case their symptoms do not get better, or get worse. Follow-up will be by daily rating of symptoms and recording of treatments used for 2 weeks in an online symptom diary. Interviews will be conducted with around 10-15 study participants, as well as with around 10-15 women who have experienced a UTI but have not been approached to take part in the study. Both groups will be asked about their experience of having a UTI, their thoughts on non-antibiotic treatments for UTIs and their thoughts on, or experience of, the feasibility trial. The primary objective is to assess the feasibility of undertaking a full trial in primary care of the effectiveness of cranberry extract to reduce antibiotic use for symptoms of acute uncomplicated UTI. The secondary objective is to conduct a preliminary assessment of the extent to which cranberry might reduce antibiotic use and symptom burden. DISCUSSION This feasibility study with embedded interviews will inform the planning and sample size calculation of an adequately powered trial to definitively determine whether cranberry helps to alleviate the symptoms of acute uncomplicated UTIs in women and whether it can safely reduce antibiotic use. TRIAL REGISTRATION ISRCTN registry, ID: 10399299. Registered on 24 January 2019.
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Lay-Flurrie SL, Sheppard JP, Stevens RJ, Mallen C, Heneghan C, Hobbs FDR, Williams B, Mant J, McManus RJ. Impact of Changes to National Hypertension Guidelines on Hypertension Management and Outcomes in the United Kingdom. Hypertension 2019; 75:356-364. [PMID: 31865798 PMCID: PMC7055938 DOI: 10.1161/hypertensionaha.119.13926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In recent years, national and international guidelines have recommended the use of out-of-office blood pressure monitoring for diagnosing hypertension. Despite evidence of cost-effectiveness, critics expressed concerns this would increase cardiovascular morbidity. We assessed the impact of these changes on the incidence of hypertension, out-of-office monitoring and cardiovascular morbidity using routine clinical data from English general practices, linked to inpatient hospital, mortality, and socio-economic status data. We studied 3 937 191 adults with median follow-up of 4.2 years (49% men, mean age=39.7 years) between April 1, 2006 and March 31, 2017. Interrupted time series analysis was used to examine the impact of changes to English hypertension guidelines in 2011 on incidence of hypertension (primary outcome). Secondary outcomes included rate of out-of-office monitoring and cardiovascular events. Across the study period, incidence of hypertension fell from 2.1 to 1.4 per 100 person-years. The change in guidance in 2011 was not associated with an immediate change in incidence (change in rate=0.01 [95% CI, -0.18-0.20]) but did result in a leveling out of the downward trend (change in yearly trend =0.09 [95% CI, 0.04-0.15]). Ambulatory monitoring increased significantly in 2011/2012 (change in rate =0.52 [95% CI, 0.43-0.60]). The rate of cardiovascular events remained unchanged (change in rate =-0.02 [95% CI, -0.05-0.02]). In summary, changes to hypertension guidelines in 2011 were associated with a stabilisation in incidence and no increase in cardiovascular events. Guidelines should continue to recommend out-of-office monitoring for diagnosis of hypertension.
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Aronson JK, Barends E, Boruch R, Brennan M, Chalmers I, Chislett J, Cunliffe-Jones P, Dahlgren A, Gaarder M, Haines A, Heneghan C, Matthews R, Maynard B, Oxman AD, Oxman M, Pullin A, Randall N, Roddam H, Schoonees A, Sharples J, Stewart R, Stott J, Tallis R, Thomas N, Vale L. Key concepts for making informed choices. Nature 2019; 572:303-306. [PMID: 31406318 DOI: 10.1038/d41586-019-02407-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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