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Howard LM, Abel KM, Atmore KH, Bick D, Bye A, Byford S, Carson LE, Dolman C, Heslin M, Hunter M, Jennings S, Johnson S, Jones I, Taylor BL, McDonald R, Milgrom J, Morant N, Nath S, Pawlby S, Potts L, Powell C, Rose D, Ryan E, Seneviratne G, Shallcross R, Stanley N, Trevillion K, Wieck A, Pickles A. Perinatal mental health services in pregnancy and the year after birth: the ESMI research programme including RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/ccht9881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background
It is unclear how best to identify and treat women with mental disorders in pregnancy and the year after birth (i.e. the perinatal period).
Objectives
(1) To investigate how best to identify depression at antenatal booking [work package (WP) 1]. (2) To estimate the prevalence of mental disorders in early pregnancy (WP1). (3) To develop and examine the efficacy of a guided self-help intervention for mild to moderate antenatal depression delivered by psychological well-being practitioners (WP1). (4) To examine the psychometric properties of the perinatal VOICE (Views On Inpatient CarE) measure of service satisfaction (WP3). (5) To examine the clinical effectiveness and cost-effectiveness of services for women with acute severe postnatal mental disorders (WPs 1–3). (6) To investigate women’s and partners’/significant others’ experiences of different types of care (WP2).
Design
Objectives 1 and 2 – a cross-sectional survey stratified by response to Whooley depression screening questions. Objective 3 – an exploratory randomised controlled trial. Objective 4 – an exploratory factor analysis, including test–retest reliability and validity assessed by association with the Client Satisfaction Questionnaire contemporaneous satisfaction scores. Objective 5 – an observational cohort study using propensity scores for the main analysis and instrumental variable analysis using geographical distance to mother and baby unit. Objective 6 – a qualitative study.
Setting
English maternity services and generic and specialist mental health services for pregnant and postnatal women.
Participants
Staff and users of mental health and maternity services.
Interventions
Guided self-help, mother and baby units and generic care.
Main outcome measures
The following measures were evaluated in WP1(i) – specificity, sensitivity, positive predictive value, likelihood ratio, acceptability and population prevalence estimates. The following measures were evaluated in WP1(ii) – participant recruitment rate, attrition and adverse events. The following measure was evaluated in WP2 – experiences of care. The following measures were evaluated in WP3 – psychometric indices for perinatal VOICE and the proportion of participants readmitted to acute care in the year after discharge.
Results
WP1(i) – the population prevalence estimate was 11% (95% confidence interval 8% to 14%) for depression and 27% (95% confidence interval 22% to 32%) for any mental disorder in early pregnancy. The diagnostic accuracy of two depression screening questions was as follows: a weighted sensitivity of 0.41, a specificity of 0.95, a positive predictive value of 0.45, a negative predictive value of 0.93 and a likelihood ratio (positive) of 8.2. For the Edinburgh Postnatal Depression Scale, the diagnostic accuracy was as follows: a weighted sensitivity of 0.59, a specificity of 0.94, a positive predictive value of 0.52, a negative predictive value of 0.95 and a likelihood ratio (positive) of 9.8. Most women reported that asking about depression at the antenatal booking appointment was acceptable, although this was reported as being less acceptable for women with mental disorders and/or experiences of abuse. Cost-effectiveness analysis suggested that both the Whooley depression screening questions and the Edinburgh Postnatal Depression Scale were more cost-effective than with the Whooley depression screening questions followed by the Edinburgh Postnatal Depression Scale or no-screen option. WP1(ii) – 53 women with depression in pregnancy were randomised. Twenty-six women received modified guided self-help [with 18 (69%) women attending four or more sessions] and 27 women received usual care. Three women were lost to follow-up (follow-up for primary outcome: 92%). At 14 weeks post randomisation, women receiving guided self-help reported fewer depressive symptoms than women receiving usual care (adjusted effect size −0.64, 95% confidence interval −1.30 to 0.06). Costs and quality-adjusted life-years were similar, resulting in a 50% probability of guided self-help being cost-effective compared with usual care at National Institute for Health and Care Excellence cost per quality-adjusted life-year thresholds. The slow recruitment rate means that a future definitive larger trial is not feasible. WP2 – qualitative findings indicate that women valued clinicians with specialist perinatal expertise across all services, but for some women generic services were able to provide better continuity of care. Involvement of family members and care post discharge from acute services were perceived as poor across services, but there was also ambivalence among some women about increasing family involvement because of a complex range of factors. WP3(i) – for the perinatal VOICE, measures from exploratory factor analysis suggested that two factors gave an adequate fit (comparative fit index = 0.97). Items loading on these two dimensions were (1) those concerning aspects of the service relating to the care of the mother and (2) those relating to care of the baby. The factors were positively correlated (0.49; p < 0.0001). Total scores were strongly associated with service (with higher satisfaction for mother and baby units, 2 degrees of freedom; p < 0.0001) and with the ‘gold standard’ Client Service Questionnaire total score (test–retest intraclass correlation coefficient 0.784, 95% confidence interval 0.643 to 0.924; p < 0.0001). WP3(ii) – 263 of 279 women could be included in the primary analysis, which shows that the odds of being readmitted to acute care was 0.95 times higher for women who were admitted to a mother and baby unit than for those not admitted to a mother and baby unit (0.95, 95% confidence interval 0.86 to 1.04; p = 0.29). Sensitivity analysis using an instrumental variable found a markedly more significant effect of admission to mother and baby units (p < 0.001) than the primary analysis. Mother and baby units were not found to be cost-effective at 1 month post discharge because of the costs of care in a mother and baby unit. Cost-effectiveness advantages may exist if the cost of mother and baby units is offset by savings from reduced readmissions in the longer term.
Limitations
Policy and service changes had an impact on recruitment. In observational studies, residual confounding is likely.
Conclusions
Services adapted for the perinatal period are highly valued by women and may be more effective than generic services. Mother and baby units have a low probability of being cost-effective in the short term, although this may vary in the longer term.
Future work
Future work should include examination of how to reduce relapses, including in after-care following discharge, and how better to involve family members.
Trial registration
This trial is registered as ISRCTN83768230 and as study registration UKCRN ID 16403.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Louise M Howard
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Kathryn M Abel
- Centre for Women’s Mental Health, The University of Manchester, Manchester, UK
| | - Katie H Atmore
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Debra Bick
- Division of Women and Children’s Health, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Amanda Bye
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sarah Byford
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Lauren E Carson
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Clare Dolman
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Margaret Heslin
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Myra Hunter
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Stacey Jennings
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Ian Jones
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | | | - Rebecca McDonald
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jeannette Milgrom
- Department of Clinical and Health Psychology, Parent–Infant Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Nicola Morant
- Division of Psychiatry, University College London, London, UK
| | - Selina Nath
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Susan Pawlby
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Laura Potts
- Biostatistics and Health Informatics, King’s College London, London, UK
| | - Claire Powell
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Diana Rose
- Service User Research Enterprise, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Elizabeth Ryan
- Biostatistics and Health Informatics, King’s College London, London, UK
| | | | - Rebekah Shallcross
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicky Stanley
- School of Social Work, Care and Community, University of Central Lancashire, Harrington, UK
| | - Kylee Trevillion
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Angelika Wieck
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Andrew Pickles
- Biostatistics and Health Informatics, King’s College London, London, UK
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Subgroup Analysis in Pulmonary Hypertension-Specific Therapy Clinical Trials: A Systematic Review. J Pers Med 2022; 12:jpm12060863. [PMID: 35743648 PMCID: PMC9224970 DOI: 10.3390/jpm12060863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 12/20/2022] Open
Abstract
Pulmonary hypertension (PH) treatment decisions are driven by the results of randomized controlled trials (RCTs). Subgroup analyses are often performed to assess whether the intervention effect will change due to the patient’s characteristics, thus allowing for individualized decisions. This review aimed to evaluate the appropriateness and interpretation of subgroup analyses performed in PH-specific therapy RCTs published between 2000 and 2020. Claims of subgroup effects were evaluated with prespecified criteria. Overall, 30 RCTs were included. Subgroup analyses presented: a high number of subgroup analyses reported, lack of prespecification, and lack of interaction tests. The trial protocol was not available for most RCTs; significant differences were found in those articles that published the protocol. Authors reported 13 claims of subgroup effect, with 12 claims meeting four or fewer of Sun’s criteria. Even when most RCTs were generally at low risk of bias and were published in high-impact journals, the credibility and general quality of subgroup analyses and subgroup claims were low due to methodological flaws. Clinicians should be skeptical of claims of subgroup effects and interpret subgroup analyses with caution, as due to their poor quality, these analyses may not serve as guidance for personalized care.
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53
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Peters E, Hardy A, Dudley R, Varese F, Greenwood K, Steel C, Emsley R, Keen N, Bowe S, Swan S, Underwood R, Longden E, Byford S, Potts L, Heslin M, Grey N, Turkington D, Fowler D, Kuipers E, Morrison A. Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial. Trials 2022; 23:429. [PMID: 35606886 PMCID: PMC9125351 DOI: 10.1186/s13063-022-06215-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 03/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists. Methods Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5–10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement. Discussion The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use. Trial registration ISRCTN93382525 (03/08/20) Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06215-x.
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Affiliation(s)
- Emmanuelle Peters
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Amy Hardy
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK. .,South London & Maudsley NHS Foundation Trust, London, UK.
| | - Robert Dudley
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Newcastle University, London, UK
| | - Filippo Varese
- School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kathryn Greenwood
- Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK.,School of Psychology, University of Sussex, London, UK
| | - Craig Steel
- Oxford Centre for Psychological Health, Oxford Health NHS Foundation Trust, Oxford, UK.,Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nadine Keen
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Swan
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Raphael Underwood
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Eleanor Longden
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Byford
- Health Service & Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Laura Potts
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Margaret Heslin
- Health Service & Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nick Grey
- Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK.,School of Psychology, University of Sussex, London, UK
| | - Doug Turkington
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Newcastle University, London, UK
| | - David Fowler
- Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK.,School of Psychology, University of Sussex, London, UK
| | - Elizabeth Kuipers
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Anthony Morrison
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Carland C, Hansra B, Parsons C, Lyubarova R, Khandelwal A. Adequate enrollment of women in cardiovascular drug trials and the need for sex-specific assessment and reporting. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100155. [PMID: 38559887 PMCID: PMC10978324 DOI: 10.1016/j.ahjo.2022.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 04/04/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death for women in the United States and globally. There is an abundance of evidence-based trials evaluating the efficacy of drug therapies to reduce morbidity and mortality in CVD. Additionally, there are well-established influences of sex, through a variety of mechanisms, on pharmacologic treatments in CVD. Despite this, the majority of drug trials are not powered to evaluate sex-specific outcomes, and much of the data that exists is gathered post hoc and through meta-analysis. The FDA established a committee in 1993 to increase the enrollment of women in clinical trials to improve this situation. Several authors, reviewing committees, and professional societies have highlighted the importance of sex-specific analysis and reporting. Despite these statements, there has not been a major improvement in representation or reporting. There are ongoing efforts to assess trial design, female representation on steering committees, and clinical trial processes to improve the representation of women. This review will describe the pharmacologic basis for the need for sex-specific assessment of cardiovascular drug therapies. It will also review the sex-specific reporting of landmark drug trials in hypertension, coronary artery disease (CAD), hyperlipidemia, and heart failure (HF). In reporting enrollment of women, several therapeutic areas like antihypertensives and newer anticoagulation trials fare better than therapeutics for HF and acute coronary syndromes. Further, drug trials and cardiometabolic or lifestyle intervention trials had a higher percentage of female participants than the device or procedural trials.
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Affiliation(s)
- Corinne Carland
- Department of Medicine, University of Pennsylvania, United States of America
| | - Barinder Hansra
- Division of Cardiology and Department of Critical Care Medicine, UPMC, United States of America
| | - Cody Parsons
- Cardiovascular Health, Stanford Health Care, United States of America
| | - Radmila Lyubarova
- Division of Cardiology, Albany Medical College, United States of America
| | - Abha Khandelwal
- Division of Cardiology, Stanford School of Medicine, United States of America
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Pirondini L, Gregson J, Owen R, Collier T, Pocock S. Covariate Adjustment in Cardiovascular Randomized Controlled Trials: Its Value, Current Practice, and Need for Improvement. JACC. HEART FAILURE 2022; 10:297-305. [PMID: 35483791 DOI: 10.1016/j.jchf.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
In randomized controlled trials, patient characteristics are expected to be well balanced between treatment groups; however, adjustment for characteristics that are prognostic can still be beneficial with a modest gain in statistical power. Nevertheless, previous reviews show that many trials use unadjusted analyses. In this article, we review current practice regarding covariate adjustment in cardiovascular trials among all 84 randomized controlled trials relating to cardiovascular disease published in the New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association during 2019. We identify trials in which use of covariate adjustment led to a change in the trial conclusions. By using these trials as case studies, along with data from the CHARM trial and simulation studies, we demonstrate some of the potential benefits and pitfalls of covariate adjustment. We discuss some of the complexities of using covariate adjustment, including how many covariates to choose, how covariates should be modeled, how to handle missing data for baseline covariates, and how adjusted analyses are viewed by regulators. We conclude that contemporary cardiovascular trials do not make best use of covariate adjustment and that more frequent use could lead to improvements in the efficiency of future trials.
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Affiliation(s)
- Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ruth Owen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Ekbäck E, von Knorring J, Burström A, Hunhammar D, Dennhag I, Molin J, Henje E. Training for Awareness, Resilience and Action (TARA) for medical students: a single-arm mixed methods feasibility study to evaluate TARA as an indicated intervention to prevent mental disorders and stress-related symptoms. BMC MEDICAL EDUCATION 2022; 22:132. [PMID: 35227281 PMCID: PMC8883651 DOI: 10.1186/s12909-022-03122-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/13/2022] [Indexed: 05/16/2023]
Abstract
BACKGROUND Medical students have a higher risk for depression, anxiety, stress-related symptoms, burnout, and suicide, and more rarely seek professional help or treatment than the general population. Appeals are being made to address the mental health and resilience of physicians-to-be. The novel program Training for Awareness, Resilience, and Action (TARA) was originally developed to treat depressed adolescents, targeting specific neuroscientific findings in this population. TARA has shown feasibility and preliminary efficacy in clinically depressed adolescents and corresponding brain-changes in mixed community adolescent samples. The present study investigated the feasibility and acceptability of TARA as a potential indicated prevention program for symptoms of depression, anxiety, stress and burnout in Swedish medical students. METHODS We conducted a single-arm trial with 23 self-selected students in their early semesters of medical school (mean age 25.38 years, 5 males and 18 females), with or without mental disorders. All participants received TARA. Self-reported symptoms of depression, anxiety, perceived stress and psychological inflexibility were collected before (T0) and after the intervention (T1). Qualitative data on the participants' experiences of TARA were collected in focus-group interviews conducted halfway through the program and upon completion of the program. Individual interviews were also conducted 2 years later. Qualitative content analysis was performed. RESULTS The mean attendance rate was 61.22% and the dropout rate was 17.40%. The Child Session Rating Scale administered after every session reflected an overall acceptable content, mean total score 34.99 out of 40.00. Trends towards improvement were seen across all outcome measures, including the Hospital Anxiety and Depression Scale Anxiety (t = 1.13, p = 0.29) and Depression (t = 1.71, p = 0.11) subscales, Perceived Stress Scale (t = 0.67, p = 0.51) and Avoidance and Fusion Questionnaire for youth (t = 1.64, p = 0.10). None of the participants deteriorated markedly during the intervention. Qualitative content analysis resulted in a main theme labeled: "An uncommon meeting-ground for personal empowerment", with 4 themes; "Acknowledging unmet needs", "Entering a free zone", "Feeling connected to oneself and others" and "Expanding self-efficacy". CONCLUSION TARA is feasible and acceptable in a mixed sample of Swedish medical students. The students' reports of entering an uncommon meeting-ground for personal empowerment supports effectiveness studies of TARA in this context.
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Affiliation(s)
- Erik Ekbäck
- Department of Clinical Science, Umeå University, Umeå, Sweden.
| | | | - Anna Burström
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - David Hunhammar
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Inga Dennhag
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Jenny Molin
- Department of Nursing, Department of Clinical Science, Umeå university, Umeå, Sweden
| | - Eva Henje
- Department of Clinical Science, Umeå University, Umeå, Sweden
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Hemilä H, Chalker E, Tukiainen J. Quantile Treatment Effect of Zinc Lozenges on Common Cold Duration: A Novel Approach to Analyze the Effect of Treatment on Illness Duration. Front Pharmacol 2022; 13:817522. [PMID: 35177991 PMCID: PMC8844493 DOI: 10.3389/fphar.2022.817522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
Calculation of the difference of means is the most common approach when analyzing treatment effects on continuous outcomes. Nevertheless, it is possible that the treatment has a different effect on patients who have a lower value of the outcome compared with patients who have a greater value of the outcome. The estimation of quantile treatment effects (QTEs) allows the analysis of treatment effects over the entire distribution of a continuous outcome, such as the duration of illness or the duration of hospital stay. Furthermore, most of these outcomes have asymmetric distributions with fat tails, and censored observations are not uncommon. These features can be accounted for in the analysis of the QTE. In this paper, we use the QTE approach to analyze the effect of zinc lozenges on common cold duration. We use the data set of the Mossad (1996) trial with zinc gluconate lozenges, and three data sets of trials with zinc acetate lozenges. In the Mossad (1996) trial, zinc gluconate lozenges shortened common cold duration on average by 4.0 days (95% CI 2.3-5.7 days). However, the QTE analysis indicates that 15- to 17-day colds were shortened by 8 days, and 2-day colds by just 1 day, for the group taking zinc lozenges. Thus, the overall 4.0-day average effect of zinc gluconate lozenges in the Mossad (1996) trial is inconsistent with our QTE findings for both short and long colds. Similar results were found in our QTE analysis of the pooled data sets of the three zinc acetate lozenge trials. The average effect of 2.7 days (95% CI 1.8-3.3 days) was inconsistent with the effects on short and long colds. The QTE approach may have broad usefulness for examining treatment effects on the duration of illness and hospital stay, and on other similar outcomes.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Elizabeth Chalker
- Biological Data Science Institute, Australian National University, Canberra, ACT, Australia
| | - Janne Tukiainen
- Department of Economics, University of Turku, Turku, Finland
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Tripepi G, Bolignano D, Jager KJ, Dekker FW, Stel VS, Zoccali C. Translational research in nephrology: prognosis. Clin Kidney J 2022; 15:205-212. [PMID: 35145636 PMCID: PMC8825211 DOI: 10.1093/ckj/sfab157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/10/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Translational research aims at reducing the gap between the results of studies focused on diagnosis, prognosis and therapy, and every day clinical practice. Prognosis is an essential component of clinical medicine. It aims at estimating the risk of adverse health outcomes in individuals, conditional to their clinical and non-clinical characteristics. There are three fundamental steps in prognostic research: development studies, in which the researcher identifies predictors, assigns the weights to each predictor, and assesses the model’s accuracy through calibration, discrimination and risk reclassification; validation studies, in which investigators test the model’s accuracy in an independent cohort of individuals; and impact studies, in which researchers evaluate whether the use of a prognostic model by clinicians improves their decision-making and patient outcome. This article aims at clarifying how to reduce the disconnection between the promises of prognostic research and the delivery of better individual health.
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Affiliation(s)
- Giovanni Tripepi
- Institute of Clinical Physiology (IFC-CNR), Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Italy
| | - Davide Bolignano
- Nephrology and Dialysis Unit, “Magna Graecia” University, Catanzaro, Italy
| | - Kitty J Jager
- Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vianda S Stel
- Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Carmine Zoccali
- Renal Research Institute, New York, NY, USA
- Associazione Ipertensione, Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia, Ospedali Riuniti, Reggio Calabria, Italy
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Ding Q, Wan S, Dowling T. Research and Scholarly Methods: Subgroup Analysis. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Qian Ding
- Department of Pharmaceutical Science College of Pharmacy, Ferris State University Big Rapids Michigan
| | - Shaowei Wan
- Palliative Care and Aging, General Internal Medicine, University of Colorado School of Medicine Anschutz Aurora Colorado
| | - Thomas Dowling
- College of Pharmacy, Ferris State University Grand Rapids Michigan
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Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, Caulley L, Chaiyakunapruk N, Greenberg D, Loder E, Mauskopf J, Mullins CD, Petrou S, Pwu RF, Staniszewska S. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:10-31. [PMID: 35031088 DOI: 10.1016/j.jval.2021.10.008] [Citation(s) in RCA: 249] [Impact Index Per Article: 124.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 05/22/2023]
Abstract
Health economic evaluations are comparative analyses of alternative courses of action in terms of their costs and consequences. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, published in 2013, was created to ensure health economic evaluations are identifiable, interpretable, and useful for decision making. It was intended as guidance to help authors report accurately which health interventions were being compared and in what context, how the evaluation was undertaken, what the findings were, and other details that may aid readers and reviewers in interpretation and use of the study. The new CHEERS 2022 statement replaces the previous CHEERS reporting guidance. It reflects the need for guidance that can be more easily applied to all types of health economic evaluation, new methods and developments in the field, and the increased role of stakeholder involvement including patients and the public. It is also broadly applicable to any form of intervention intended to improve the health of individuals or the population, whether simple or complex, and without regard to context (such as healthcare, public health, education, and social care). This Explanation and Elaboration Report presents the new CHEERS 2022 28-item checklist with recommendations and explanation and examples for each item. The CHEERS 2022 statement is primarily intended for researchers reporting economic evaluations for peer-reviewed journals and the peer reviewers and editors assessing them for publication. Nevertheless, we anticipate familiarity with reporting requirements will be useful for analysts when planning studies. It may also be useful for health technology assessment bodies seeking guidance on reporting, given that there is an increasing emphasis on transparency in decision making.
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Affiliation(s)
- Don Husereau
- University of Ottawa, School of Epidemiology and Public Health, Ottawa, Ontario, Canada and Institute of Health Economics, Edmonton, Alberta, Canada (Husereau).
| | | | - Federico Augustovski
- Health Technology Assessment and Health Economics Department of the Institute for Clinical Effectiveness and Health Policy (IECS- CONICET), Buenos Aires; University of Buenos Aires, Buenos Aires; CONICET (National Scientific and Technical Research Council), Buenos Aires, Argentina
| | - Esther de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Andrew H Briggs
- London School of Hygiene and Tropical Medicine, London, England, UK
| | | | - Lisa Caulley
- Department of Otolaryngology - Head & Neck Surgery, University of Ottawa, Ontario, Canada; Clinical Epidemiology Program and Center for Journalology, Ottawa Hospital Research Institute, Ontario, Canada; Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Elizabeth Loder
- Harvard Medical School, Boston, MA, USA; The BMJ, London, UK
| | - Josephine Mauskopf
- RTI Health Solutions, RTI International, Research Triangle Park, NC, USA
| | - C Daniel Mullins
- School of Pharmacy, University of Maryland Baltimore, Baltimore, MD, USA
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Raoh-Fang Pwu
- National Hepatitis C Program Office, Ministry of Health and Welfare, Taipei City, Taiwan
| | - Sophie Staniszewska
- Warwick Research in Nursing, University of Warwick Warwick Medical School, Warwick, UK
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Samuel M, Rivard L, Nault I, Gula L, Essebag V, Parkash R, Sterns LD, Khairy P, Sapp JL. Comparative effectiveness of ventricular tachycardia ablation vs. escalated antiarrhythmic drug therapy by location of myocardial infarction: a sub-study of the VANISH trial. Europace 2021; 24:948-958. [PMID: 34964475 PMCID: PMC9282915 DOI: 10.1093/europace/euab298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/16/2021] [Indexed: 12/31/2022] Open
Abstract
AIMS Complexity of the ventricular tachycardia (VT) substrate and the size and thickness of infarction area border zones differ based on location of myocardial infarctions (MIs). These differences may translate into heterogeneity in the effectiveness of treatments. This study aims to examine the influence of infarct location on the effectiveness of VT ablation in comparison with escalated pharmacological therapy in patients with prior MI and antiarrhythmic drug (AAD)-refractory VT. METHODS AND RESULTS VANISH trial participants were categorized based on the presence or absence of an inferior MI scar. Inverse probability of treatment weighted Cox models were calculated for each subgroup. Of 259 randomized patients (median age 69.8 years, 7.0% women), 135 had an inferior MI and 124 had a non-inferior MI. Among patients with an inferior MI, no statistically significant difference in the composite primary outcome of all-cause mortality, appropriate implantable cardioverter-defibrillator (ICD) shock, and VT storm was detected between treatment arms [adjusted hazard ratio (aHR) 0.80, 95% confidence interval (CI) 0.51-1.20]. In contrast, patients with non-inferior MIs had a statistically significant reduction in the incidence of the primary outcome with ablation (aHR 0.48, 95% CI 0.27-0.86). In a sensitivity analysis of anterior MI patients (n = 83), a trend towards a reduction in the primary outcome with ablation was detected (aHR 0.50, 95% CI 0.23-1.09). CONCLUSION The effectiveness of VT ablation versus escalated AADs varies based on the location of the MI. Patients with MI scars located only in non-inferior regions of the ventricles derive greater benefit from VT ablation in comparison to escalation of AADs in reducing VT-related events.
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Affiliation(s)
- Michelle Samuel
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Lena Rivard
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Isabelle Nault
- Department of Medicine, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Lorne Gula
- Department of Medicine, Western University, London, Ontario, Canada
| | - Vidal Essebag
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ratika Parkash
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Room 2501B Halifax Infirmary, 1796 Summer St, Halifax, Nova Scotia B3H 3A7, Canada
| | - Laurence D Sterns
- Department of Medicine, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Paul Khairy
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - John L Sapp
- Corresponding author. Tel: +1 902 473 4272; fax: +1 902 473 3158. E-mail address:
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Cruwys T, Haslam C, Rathbone JA, Williams E, Haslam SA. Groups 4 Health protects against unanticipated threats to mental health: Evaluating two interventions during COVID-19 lockdown among young people with a history of depression and loneliness. J Affect Disord 2021; 295:316-322. [PMID: 34488085 PMCID: PMC8413117 DOI: 10.1016/j.jad.2021.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/05/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decades of research indicate that when social connectedness is threatened, mental health is at risk. However, extant interventions to tackle loneliness have had only modest success, and none have been trialled under conditions of such threat. METHOD 174 young people with depression and loneliness were randomised to one of two evidence-based treatments: cognitive behaviour therapy (CBT) or Groups 4 Health (G4H), an intervention designed to increase social group belonging. Depression, loneliness, and well-being outcomes were evaluated at one-year follow-up; COVID-19 lockdown restrictions were imposed partway through follow-up assessments. This provided a quasi-experimental test of the utility of each intervention in the presence (lockdown group) and absence (control group) of a threat to social connectedness. RESULTS At one-year follow-up, participants in lockdown reported significantly poorer wellbeing than controls who completed follow-up before lockdown, t(152)=2.41, p=.017. Although both CBT and G4H led to symptom improvement, the benefits of G4H were more robust following an unanticipated threat to social connectedness for depression (χ2(16)=31.35, p=.001), loneliness (χ2(8)=21.622, p=.006), and wellbeing (χ2(8)=22.938, p=.003). LIMITATIONS Because the COVID-19 lockdown was unanticipated, this analysis represents an opportunistic use of available data. As a result, we could not measure the specific impact of restrictions on participants, such as reduced income, degree of isolation, or health-related anxieties. CONCLUSIONS G4H delivered one year prior to COVID-19 lockdown offered greater protection than CBT against relapse of loneliness and depression symptoms. Implications are discussed with a focus on how these benefits might be extended to other life stressors and transitions.
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Affiliation(s)
- Tegan Cruwys
- Research School of Psychology, The Australian National University, Australia.
| | | | | | - Elyse Williams
- School of Psychology, The University of Queensland, Australia
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Suchting R, Teixeira AL, Ahn B, Colpo GD, Park J, Ahn H. Changes in Brain-derived Neurotrophic Factor From Active and Sham Transcranial Direct Current Stimulation in Older Adults With Knee Osteoarthritis. Clin J Pain 2021; 37:898-903. [PMID: 34757341 PMCID: PMC8589111 DOI: 10.1097/ajp.0000000000000987] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/01/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Previous work has shown effects of transcranial direct current stimulation (tDCS) on clinical pain measures, qualitative sensory testing measures, and peripheral inflammation. The present report extends this research to investigate the effect of tDCS on brain-derived neurotrophic factor (BDNF) levels. MATERIALS AND METHODS This secondary analysis examined a sample of 40 older adults (50 to 70 y old) with symptomatic knee osteoarthritis randomly assigned in a 1:1 fashion to active (n=20) or sham (n=20) tDCS for 20 minutes on 5 consecutive days. BDNF was measured before the first session and after the final treatment session. Generalized linear modeling evaluated BDNF plasma levels as a function of tDCS group, adjusted for baseline. Bayesian statistical inference was used to quantify the probability that effects of the treatment exist. RESULTS Generalized linear modeling indicated a 90.4% posterior probability that the sham condition had 49.9% higher BDNF at the end of treatment, controlling for baseline. Follow-up analyses within the active TDCS group supported an association between change in BDNF and change in clinical pain, and exploratory analyses found an effect of tDCS on irisin. DISCUSSION Results indicated that tDCS could be a potential nonpharmacological treatment to decrease BDNF levels, which may in turn decrease pain. This study adds to a growing literature suggesting that tDCS affects cortical excitability, and consequentially, the neural circuits implicated in pain modulation. In addition to a direct connection to analgesia, BDNF changes may reflect tDCS-induced changes in different cortical areas and/or neural circuits.
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Affiliation(s)
- Robert Suchting
- UTHealth McGovern Medical School, Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Antonio L. Teixeira
- UTHealth McGovern Medical School, Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Brian Ahn
- UTHealth McGovern Medical School, Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gabriela D. Colpo
- UTHealth McGovern Medical School, Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juyoung Park
- College of Social Work & Criminal Justice, Phyllis and Harvey Sandler School of Social Work, Florida Atlantic University, Boca Raton, FL, USA
| | - Hyochol Ahn
- College of Nursing, Florida State University, Tallahassee, FL, USA
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Otobe Y, Yamada M, Hiraki K, Onari S, Taki Y, Sumi H, Hachisuka R, Han W, Takahashi M, Suzuki M, Kimura Y, Koyama S, Masuda H, Shibagaki Y, Tominaga N. Physical Exercise Improves Cognitive Function in Older Adults with Stage 3-4 Chronic Kidney Disease: A Randomized Controlled Trial. Am J Nephrol 2021; 52:929-939. [PMID: 34847564 DOI: 10.1159/000520230] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/09/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) exhibit a higher probability of having cognitive impairment or dementia than those without CKD. The beneficial effects of physical exercise on cognitive function are known in the general older population, but more research is required in older adults with CKD. METHODS Eighty-one outpatients (aged ≥65 years) with CKD stage G3-G4 were assessed for eligibility. Among them, 60 were randomized (single-center, unblinded, and stratified) and 53 received the allocated intervention (exercise n = 27, control n = 26). Patients in the exercise group undertook group-exercise training at our facility once weekly and independent exercises at home twice weekly or more, for 24 weeks. Patients in the control group received general care. General and specific cognitive functions (memory, attention, executive, and verbal) were measured, and differences in their scores at baseline and at the 24-week follow-up visit were assessed between the 2 groups. RESULTS Forty-four patients completed the follow-up at 24 weeks (exercise n = 23, control n = 21). Patients in the exercise group showed significantly greater changes in Wechsler Memory Scale-Revised Logical Memory delayed recall (exercise effect: 2.82, 95% CI: 0.46-5.19, p = 0.03), and immediate and delayed recall (exercise effect: 5.97, 95% CI: 1.13-10.81, p = 0.02) scores than those in the control group. CONCLUSIONS The 24-week exercise intervention significantly improved the memory function in older adults with pre-dialysis CKD. This randomized controlled trial suggests that physical exercise is a useful nonpharmacological strategy for preventing cognitive decline in these patients.
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Affiliation(s)
- Yuhei Otobe
- Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Minoru Yamada
- Faculty of Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Koji Hiraki
- Rehabilitation Center, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Satoshi Onari
- Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
| | - Yasuhiro Taki
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hirofumi Sumi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Rina Hachisuka
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Wei Han
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaki Takahashi
- Department of Medical Informatics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Mizue Suzuki
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Yosuke Kimura
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
- Department of Electrical Engineering, Health and Sports Technology Course, Kanto Gakuin University, Yokohama, Japan
| | - Shingo Koyama
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Hiroaki Masuda
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Naoto Tominaga
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Tosetto A, Rocca B, Petrucci G, Betti S, Soldati D, Rossi E, Timillero A, Cavalca V, Porro B, Iurlo A, Cattaneo D, Bucelli C, Dragani A, Di Ianni M, Ranalli P, Palandri F, Vianelli N, Beggiato E, Lanzarone G, Ruggeri M, Carli G, Elli EM, Priolo S, Randi ML, Bertozzi I, Loscocco GG, Ricco A, Specchia G, Vannucchi AM, Rodeghiero F, De Stefano V, Patrono C. Association of Platelet Thromboxane Inhibition by Low-Dose Aspirin With Platelet Count and Cytoreductive Therapy in Essential Thrombocythemia. Clin Pharmacol Ther 2021; 111:939-949. [PMID: 34743317 PMCID: PMC9299058 DOI: 10.1002/cpt.2485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/27/2021] [Indexed: 01/14/2023]
Abstract
Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by enhanced platelet production and thrombotic complications. The inhibition of platelet cyclooxygenase (COX) activity by the standard once‐daily aspirin is mostly incomplete due to accelerated thrombopoiesis. The phase II Aspirin Regimens in EsSential thrombocythemia (ARES) trial has recently compared the efficacy of once‐ vs. twice‐ or three‐times daily low‐dose aspirin in inhibiting platelet thromboxane (TX) A2 production, as reflected by serum (s) TXB2 measurements. The present substudy characterized the determinants of the highly variable response to the standard aspirin 100 mg once‐daily regimen in fully compliant patients with ET and the effects of the experimental dosing regimens on response variability. By multivariable analysis, the platelet count (directly) and cytoreductive treatment (inversely) were significantly associated with sTXB2 values in 218 patients with ET. However, the platelet count positively correlated with sTXB2 in patients not being treated with cytoreductive drugs (ρ = 0.51, P < 0.01, n = 84), but not in patients on cytoreduction. Patients in the lowest sTXB2 quartile were older, more often on cytoreductive drugs, had lower platelet count and Janus‐Associated Kinase2 (JAK2)‐V617F allele frequency as compared with patients in the upper sTXB2 quartiles. After 2 weeks of a twice‐ or 3‐times daily aspirin regimen, the association between the platelet count and sTXB2 became similar in cytoreduced and non‐cytoreduced patients. In conclusion, the platelet count appears the strongest determinant of TXA2 inhibition by once‐daily low‐dose aspirin in ET, with different patterns depending of cytoreductive treatment. More frequent aspirin dosing restores adequate platelet inhibition and reduces interindividual variability, independently of cytoreduction.
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Affiliation(s)
| | - Bianca Rocca
- Department of Safety and Bioethics Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Petrucci
- Department of Safety and Bioethics Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Betti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Denise Soldati
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Rossi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Section of Hematology, Catholic University School of Medicine, Rome, Italy
| | | | | | | | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | | | - Mauro Di Ianni
- Hematology Department, S. Spirito Hospital, Pescara, Italy
| | - Paola Ranalli
- Hematology Department, S. Spirito Hospital, Pescara, Italy
| | - Francesca Palandri
- Dipartimento Attività Integrata, Dipartimento di Oncologia e di Ematologia, Azienda Ospedaliero, Universitaria di Bologna IRCCS Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Nicola Vianelli
- Dipartimento Attività Integrata, Dipartimento di Oncologia e di Ematologia, Azienda Ospedaliero, Universitaria di Bologna IRCCS Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Eloise Beggiato
- Department of Oncology, Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giuseppe Lanzarone
- Department of Oncology, Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Ruggeri
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Giuseppe Carli
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Elena Maria Elli
- Division of Haematology and Bone Marrow Transplantation Unit, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Stefania Priolo
- Division of Haematology and Bone Marrow Transplantation Unit, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | | | - Irene Bertozzi
- Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Giuseppe Gaetano Loscocco
- Department of Experimental and Clinical Medicine, CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Firenze, Firenze, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation (DETO), Hematology Section, University of Bari Aldo Moro, Bari, Italy
| | | | - Alessandro Maria Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Firenze, Firenze, Italy
| | | | - Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Section of Hematology, Catholic University School of Medicine, Rome, Italy
| | - Carlo Patrono
- Department of Safety and Bioethics Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
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Zhang D, Lin X, Lv YW, Li ZS, Hu LH. Accurate and detailed research methods are crucial for natural history research of recurrent acute pancreatitis. Dig Liver Dis 2021; 53:1517. [PMID: 34404620 DOI: 10.1016/j.dld.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Di Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Xi Lin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Yan-Wei Lv
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.
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Schmitz JM, Lane SD, Weaver MF, Narayana PA, Hasan KM, Russell DD, Suchting R, Green CE. Targeting white matter neuroprotection as a relapse prevention strategy for treatment of cocaine use disorder: Design of a mechanism-focused randomized clinical trial. Contemp Clin Trials 2021; 111:106603. [PMID: 34688917 DOI: 10.1016/j.cct.2021.106603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 10/20/2022]
Abstract
Cocaine use continues to be a significant public health problem with limited treatment options and no approved pharmacotherapies. Cognitive-behavioral therapy (CBT) remains the mainstay treatment for preventing relapse, however, people with chronic cocaine use display cognitive impairments that are associated with poor response to CBT. Emerging evidence in animal and human studies suggests that the peroxisome proliferator-activated receptor-gamma (PPAR- γ) agonist, pioglitazone, improves white matter integrity that is essential for cognitive function. This project will determine whether adjunctive use of pioglitazone enhances the effect of CBT in preventing relapse during the early phase of recovery from cocaine use disorder. This paper describes the design of a mechanism-focused phase 2 randomized clinical trial that aims first to evaluate the effects of pioglitazone on targeted mechanisms related to white matter integrity, cognitive function, and cocaine craving; and second, to evaluate the extent to which improvements on target mechanisms predict CBT response. Positive results will support pioglitazone as a potential cognitive enhancing agent to advance to later stage medication development research.
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Affiliation(s)
- Joy M Schmitz
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, USA.
| | - Scott D Lane
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, USA
| | - Michael F Weaver
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, USA
| | - Ponnada A Narayana
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center at Houston, USA
| | - Khader M Hasan
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center at Houston, USA
| | | | - Robert Suchting
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, USA
| | - Charles E Green
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, USA; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, USA
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Yuan A, Wang L, Tan MT. Set-regression with applications to subgroup analysis. Stat Med 2021; 41:180-193. [PMID: 34672000 DOI: 10.1002/sim.9229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022]
Abstract
Regression is a commonly used statistical model. It is the conditional mean of the response given covariates μ ( x ) = E ( Y | X = x ) . However, in some practical problems, the interest is the conditional mean of the response given the covariates belonging to some set A. Notably, in precision medicine and subgroup analysis in clinical trials, the aim is to identify subjects who benefit the most from the treatment, or identify an optimal set in the covariate space which manifests treatment favoritism if a subject's covariates fall in this set and the subject is classified to the favorable treatment subgroup. Existing methods for subgroup analysis achieve this indirectly by using classical regression. This motivates us to develop a new type of regression: set-regression, defined as μ ( A ) = E ( Y | X ∈ A ) which directly addresses the subgroup analysis problem. This extends not only the classical regression model but also improves recursive partitioning and support vector machine approaches, and is particularly suitable for objectives involving optimization of the regression over sets, such as subgroup analysis. We show that the new versatile set-regression identifies the subgroup with increased accuracy. It is easy to use. Simulation studies also show superior performance of the proposed method in finite samples.
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Affiliation(s)
- Ao Yuan
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Lida Wang
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Ming T Tan
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, District of Columbia, USA
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Zhang P, Liu P, Ma J, Shentu Y. Value Function Guided Subgroup Identification via Gradient Tree Boosting: A Framework to Handle Multiple Outcomes for Optimal Treatment Recommendation. Stat Biopharm Res 2021. [DOI: 10.1080/19466315.2021.1972832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Peng Liu
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
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Blakely ML, Tyson JE, Lally KP, Hintz SR, Eggleston B, Stevenson DK, Besner GE, Das A, Ohls RK, Truog WE, Nelin LD, Poindexter BB, Pedroza C, Walsh MC, Stoll BJ, Geller R, Kennedy KA, Dimmitt RA, Carlo WA, Cotten CM, Laptook AR, Van Meurs KP, Calkins KL, Sokol GM, Sanchez PJ, Wyckoff MH, Patel RM, Frantz ID, Shankaran S, D’Angio CT, Yoder BA, Bell EF, Watterberg KL, Martin CA, Harmon CM, Rice H, Kurkchubasche AG, Sylvester K, Dunn JCY, Markel TA, Diesen DL, Bhatia AM, Flake A, Chwals WJ, Brown R, Bass KD, St. Peter SD, Shanti CM, Pegoli W, Skarda D, Shilyansky J, Lemon DG, Mosquera RA, Peralta-Carcelen M, Goldstein RF, Vohr BR, Purdy IB, Hines AC, Maitre NL, Heyne RJ, DeMauro SB, McGowan EC, Yolton K, Kilbride HW, Natarajan G, Yost K, Winter S, Colaizy TT, Laughon MM, Lakshminrusimha S, Higgins RD. Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial. Ann Surg 2021; 274:e370-e380. [PMID: 34506326 PMCID: PMC8439547 DOI: 10.1097/sla.0000000000005099] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.
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MESH Headings
- Drainage
- Enterocolitis, Necrotizing/mortality
- Enterocolitis, Necrotizing/psychology
- Enterocolitis, Necrotizing/surgery
- Feasibility Studies
- Female
- Humans
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/psychology
- Infant, Premature, Diseases/surgery
- Intestinal Perforation/mortality
- Intestinal Perforation/psychology
- Intestinal Perforation/surgery
- Laparotomy
- Male
- Neurodevelopmental Disorders/diagnosis
- Neurodevelopmental Disorders/epidemiology
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Martin L. Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kevin P. Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Barry Eggleston
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - David K. Stevenson
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Gail E. Besner
- Department of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Rockville, MD
| | - Robin K. Ohls
- University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Leif D. Nelin
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Brenda B. Poindexter
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Rachel Geller
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Reed A. Dimmitt
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Abbot R. Laptook
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Kara L. Calkins
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Pablo J. Sanchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ravi M. Patel
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Ivan D. Frantz
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Bradley A. Yoder
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Colin A. Martin
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Carroll M. Harmon
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Surgery, University of Buffalo, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Henry Rice
- Division of Pediatric General Surgery, Duke University, Durham, NC
| | - Arlet G. Kurkchubasche
- Department of Pediatric Surgery, Hasbro Children’s Hospital, Brown University, Providence, RI
| | - Karl Sylvester
- Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - James C. Y. Dunn
- Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
- Department of Pediatric Surgery, University of California, Los Angeles, CA
| | - Troy A. Markel
- Department of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Diana L. Diesen
- Department of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amina M. Bhatia
- Department of Pediatric Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Alan Flake
- Department of Pediatric Surgery, University of Pennsylvania, Philadelphia, PA
| | - Walter J. Chwals
- Department of Pediatric Surgery, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Rebeccah Brown
- Department of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kathryn D. Bass
- Division of Pediatric Surgery, University of Buffalo, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Shawn D. St. Peter
- Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO
| | | | - Walter Pegoli
- Department of Pediatric Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - David Skarda
- Department of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | | | - David G. Lemon
- Department of Pediatric Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ricardo A. Mosquera
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Betty R. Vohr
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
| | - Isabell B. Purdy
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Abbey C. Hines
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Nathalie L. Maitre
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Elisabeth C. McGowan
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Kimberly Yolton
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Kelley Yost
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sarah Winter
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Matthew M. Laughon
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
- College of Health and Human Services, George Mason University, Fairfax, VA
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Webber HE, Kessler DA, Lathan EC, Wardle MC, Green CE, Schmitz JM, Lane SD, Vujanovic AA. Posttraumatic stress symptom clusters differentially predict late positive potential to cocaine imagery cues in trauma-exposed adults with cocaine use disorder. Drug Alcohol Depend 2021; 227:108929. [PMID: 34340161 PMCID: PMC8464512 DOI: 10.1016/j.drugalcdep.2021.108929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND While studies have investigated the effects of posttraumatic stress disorder (PTSD) symptoms on substance use, information on these associations in the context of drug cue reactivity is lacking, which can provide meaningful information about risk for relapse. The current study assessed the associations between PTSD symptom clusters and reactivity to cues in trauma-exposed adults with cocaine use disorder. METHODS We recorded electroencephalogram on 52 trauma-exposed participants (Mage = 51.3; SD = 7.0; 15.4 % women) diagnosed with cocaine use disorder while they viewed pleasant (i.e., erotic, romantic, sweet foods), unpleasant (i.e., mutilations, violence, accidents), neutral, and cocaine-related images. Reactivity was measured with the late positive potential (LPP), an indicator of motivational relevance. It was hypothesized that individuals with greater PTSD avoidance and negative alterations in cognition and mood (NACM) symptoms, as determined by the PTSD Checklist for DSM-5 (PCL-5), would have higher LPPs to cocaine-related images, indicating greater cue reactivity. RESULTS Linear mixed modeling indicated that higher NACM symptomatology was associated with higher LPPs to cocaine cues and higher arousal/reactivity was associated with lower LPPs to cocaine cues. CONCLUSIONS These results highlight the potential clinical utility of the LPP in assessing drug cue reactivity in trauma-exposed adults with substance use disorder.
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Affiliation(s)
- Heather E. Webber
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Emma C. Lathan
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Margaret C. Wardle
- Department of Psychology, University of Illinois at Chicago, Chicago, IL
| | - Charles E. Green
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science, Center at Houston, Houston, TX
| | - Joy M. Schmitz
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Scott D. Lane
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
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Hu L, Ji J, Li F. Estimating heterogeneous survival treatment effect in observational data using machine learning. Stat Med 2021; 40:4691-4713. [PMID: 34114252 PMCID: PMC9827499 DOI: 10.1002/sim.9090] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 01/12/2023]
Abstract
Methods for estimating heterogeneous treatment effect in observational data have largely focused on continuous or binary outcomes, and have been relatively less vetted with survival outcomes. Using flexible machine learning methods in the counterfactual framework is a promising approach to address challenges due to complex individual characteristics, to which treatments need to be tailored. To evaluate the operating characteristics of recent survival machine learning methods for the estimation of treatment effect heterogeneity and inform better practice, we carry out a comprehensive simulation study presenting a wide range of settings describing confounded heterogeneous survival treatment effects and varying degrees of covariate overlap. Our results suggest that the nonparametric Bayesian Additive Regression Trees within the framework of accelerated failure time model (AFT-BART-NP) consistently yields the best performance, in terms of bias, precision, and expected regret. Moreover, the credible interval estimators from AFT-BART-NP provide close to nominal frequentist coverage for the individual survival treatment effect when the covariate overlap is at least moderate. Including a nonparametrically estimated propensity score as an additional fixed covariate in the AFT-BART-NP model formulation can further improve its efficiency and frequentist coverage. Finally, we demonstrate the application of flexible causal machine learning estimators through a comprehensive case study examining the heterogeneous survival effects of two radiotherapy approaches for localized high-risk prostate cancer.
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Affiliation(s)
- Liangyuan Hu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
| | - Jiayi Ji
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
- Center for Methods in Implementation and Prevention Science, Yale University School of Public Health, New Haven, Connecticut
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73
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Sarge T, Baedorf-Kassis E, Banner-Goodspeed V, Novack V, Loring SH, Gong MN, Cook D, Talmor D, Beitler JR. Effect of Esophageal Pressure-Guided Positive End-Expiratory Pressure on Survival from Acute Respiratory Distress Syndrome: A Risk-Based and Mechanistic Reanalysis of the EPVent-2 Trial. Am J Respir Crit Care Med 2021; 204:1153-1163. [PMID: 34464237 DOI: 10.1164/rccm.202009-3539oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE In acute respiratory distress syndrome (ARDS), the effect of positive end-expiratory pressure (PEEP) may depend on the extent to which multiorgan dysfunction contributes to risk of death, and the precision with which PEEP is titrated to attenuate atelectrauma without exacerbating overdistension. OBJECTIVE To evaluate whether multiorgan dysfunction and lung mechanics modified treatment effect in EPVent-2, a multicenter trial of esophageal pressure (PES)-guided PEEP versus empirical high PEEP in moderate-to-severe ARDS. METHODS This post-hoc reanalysis of EPVent-2 evaluated for heterogeneity of treatment effect on mortality by baseline multiorgan dysfunction, determined via Acute Physiology and Chronic Health Evaluation-II (APACHE-II). It also evaluated whether PEEP titrated to end-expiratory transpulmonary pressure near 0 cmH2O was associated with survival. MEASUREMENTS AND MAIN RESULTS All 200 trial participants were included. Treatment effect on 60-day mortality differed by multiorgan dysfunction severity (p=0.03 for interaction). PES-guided PEEP was associated with lower mortality among patients with lower APACHE-II (HR 0.43, 95% CI 0.20-0.92 for APACHE-II less than median) and may have had the opposite effect in patients with higher APACHE-II (HR 1.69; 95% CI 0.93-3.05). Independent of treatment group or multiorgan dysfunction severity, mortality was lowest when PEEP titration achieved end-expiratory transpulmonary pressure near 0 cmH2O. CONCLUSIONS The effect on survival of PES-guided PEEP, compared to empirical high PEEP, differed by multiorgan dysfunction severity. Independent of multiorgan dysfunction, PEEP titrated to end-expiratory transpulmonary pressure closer to 0 cmH2O was associated with greater survival than more positive or negative values. These findings warrant prospective testing in a future trial.
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Affiliation(s)
- Todd Sarge
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Elias Baedorf-Kassis
- Beth Israel Deaconess Medical Center, 1859, Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Valerie Banner-Goodspeed
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Victor Novack
- Soroka Medical Center, 26746, Clinical Research Center, Beer-Sheva, Israel
| | - Stephen H Loring
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Michelle N Gong
- Montefiore Medical Center, 2013, Division of Critical Care Medicine, Bronx, New York, United States.,Albert Einstein College of Medicine, 2006, Bronx, New York, United States
| | - Deborah Cook
- McMaster University, 3710, Department of Medicine, Pathology & Molecular Medicine, Hamilton, Ontario, Canada
| | - Daniel Talmor
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Jeremy R Beitler
- Columbia University College of Physicians and Surgeons, 12294, Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, New York, New York, United States.,NewYork-Presbyterian Hospital, 25065, New York, New York, United States;
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Gelbard RB, Cripps MW. Pitfalls in Study Interpretation. Surg Infect (Larchmt) 2021; 22:646-650. [PMID: 34270363 DOI: 10.1089/sur.2021.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The goal of a randomized or observational study is to develop an unbiased and reliable answer to a therapeutic question. However, there are multiple pitfalls in the reporting and interpretation of data that can compromise our ability to evaluate the pragmatism and the effectiveness of the intervention being studied. Researchers must be conscious of these biases when designing their studies, just as readers must be aware of these potential pitfalls when interpreting results. Results: The purpose of this review is to highlight some of the more common sources of bias in clinical research, including internal and external validity, type 1 and type 2 error, reporting of secondary outcomes, the use of subgroup analyses, and multiple comparisons. This article also discusses potential solutions to these issues, including using the fragility index to understand the robustness of study conclusions, and generating an E value to determine the degree of unmeasured confounding in a study. Conclusions: With an understanding of these pitfalls, readers can critically review scientific literature and ascertain the validity of the conclusions.
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Affiliation(s)
- Rondi B Gelbard
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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75
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Hsu YC, Huang YT, Lin JT. Fibrosis in patients with chronic hepatitis B and minimally raised ALT during tenofovir therapy - Authors' reply. THE LANCET. INFECTIOUS DISEASES 2021; 21:911. [PMID: 34174231 DOI: 10.1016/s1473-3099(21)00331-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Yao-Chun Hsu
- Center for Liver Diseases, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, I-Shou University, College of Medicine, Kaohsiung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung 40447, Taiwan
| | - Yen-Tsung Huang
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Jaw-Town Lin
- Digestive Medicine Center, China Medical University, Taichung 40447, Taiwan.
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Yang S, Li F, Thomas LE, Li F. Covariate adjustment in subgroup analyses of randomized clinical trials: A propensity score approach. Clin Trials 2021; 18:570-581. [PMID: 34269087 DOI: 10.1177/17407745211028588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Subgroup analyses are frequently conducted in randomized clinical trials to assess evidence of heterogeneous treatment effect across patient subpopulations. Although randomization balances covariates within subgroups in expectation, chance imbalance may be amplified in small subgroups and adversely impact the precision of subgroup analyses. Covariate adjustment in overall analysis of randomized clinical trial is often conducted, via either analysis of covariance or propensity score weighting, but covariate adjustment for subgroup analysis has been rarely discussed. In this article, we develop propensity score weighting methodology for covariate adjustment to improve the precision and power of subgroup analyses in randomized clinical trials. METHODS We extend the propensity score weighting methodology to subgroup analyses by fitting a logistic regression propensity model with pre-specified covariate-subgroup interactions. We show that, by construction, overlap weighting exactly balances the covariates with interaction terms in each subgroup. Extensive simulations were performed to compare the operating characteristics of unadjusted estimator, different propensity score weighting estimators and the analysis of covariance estimator. We apply these methods to the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training trial to evaluate the effect of exercise training on 6-min walk test in several pre-specified subgroups. RESULTS Standard errors of the adjusted estimators are smaller than those of the unadjusted estimator. The propensity score weighting estimator is as efficient as analysis of covariance, and is often more efficient when subgroup sample size is small (e.g. <125), and/or when outcome model is misspecified. The weighting estimators with full-interaction propensity model consistently outperform the standard main-effect propensity model. CONCLUSION Propensity score weighting is a transparent and objective method to adjust chance imbalance of important covariates in subgroup analyses of randomized clinical trials. It is crucial to include the full covariate-subgroup interactions in the propensity score model.
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Affiliation(s)
- Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Fan Li
- Department of Statistical Science, Duke University, Durham, NC, USA
| | - Laine E Thomas
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
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Allen L, Ashford PA, Beeson E, Byford S, Chow J, Dalgleish T, Danese A, Finn J, Goodall B, Grainger L, Hammond M, Humphrey A, Mahoney-Davies G, Morant N, Shepstone L, Sims E, Smith P, Stallard P, Swanepoel A, Trickey D, Trigg K, Wilson J, Meiser-Stedman R. DECRYPT trial: study protocol for a phase II randomised controlled trial of cognitive therapy for post-traumatic stress disorder (PTSD) in youth exposed to multiple traumatic stressors. BMJ Open 2021; 11:e047600. [PMID: 34210731 PMCID: PMC8252885 DOI: 10.1136/bmjopen-2020-047600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a distressing and disabling condition that affects significant numbers of children and adolescents. Youth exposed to multiple traumas (eg, abuse, domestic violence) are at particular risk of developing PTSD. Cognitive therapy for PTSD (CT-PTSD), derived from adult work, is a theoretically informed, disorder-specific form of trauma-focused cognitive-behavioural therapy. While efficacious for child and adolescent single-event trauma samples, its effectiveness in routine settings with more complex, multiple trauma-exposed youth has not been established. The Delivery of Cognitive Therapy for Young People after Trauma randomised controlled trial (RCT) examines the effectiveness of CT-PTSD for treating PTSD following multiple trauma exposure in children and young people in comparison with treatment as usual (TAU). METHODS/DESIGN This protocol describes a two-arm, patient-level, single blind, superiority RCT comparing CT-PTSD (n=60) with TAU (n=60) in children and young people aged 8-17 years with a diagnosis of PTSD following multiple trauma exposure. The primary outcome is PTSD severity assessed using the Children's Revised Impact of Event Scale (8-item version) at post-treatment (ie, approximately 5 months post-randomisation). Secondary outcomes include structured interview assessment for PTSD, complex PTSD symptoms, depression and anxiety, overall functioning and parent-rated mental health. Mid-treatment and 11-month and 29-month post-randomisation assessments will also be completed. Process-outcome evaluation will consider which mechanisms underpin or moderate recovery. Qualitative interviews with the young people, their families and their therapists will be undertaken. Cost-effectiveness of CT-PTSD relative to TAU will be also be assessed. ETHICS AND DISSEMINATION This trial protocol has been approved by a UK Health Research Authority Research Ethics Committee (East of England-Cambridge South, 16/EE/0233). Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations and clinical workshops. TRIAL REGISTRATION ISRCTN12077707. Registered 24 October 2016 (http://www.isrctn.com/ISRCTN12077707). Trial recruitment commenced on 1 February 2017. It is anticipated that recruitment will continue until June 2021, with 11-month assessments being concluded in May 2022.
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Affiliation(s)
- Leila Allen
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Polly-Anna Ashford
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ella Beeson
- Hertfordshire Partnership University NHS Foundation Trust, Hatfield, UK
| | - Sarah Byford
- King's Health Economics, King's College London, London, UK
| | - Jessica Chow
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Tim Dalgleish
- MRC Cognition and Brain Sciences Unit, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Andrea Danese
- Department of Child and Adolescent Psychiatry, King's College London Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Social, Genetic and Developmental Psychiatry Centre, King's College London, London, UK
| | - Jack Finn
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ben Goodall
- North East London NHS Foundation Trust, Rainham, UK
| | - Lauren Grainger
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Matthew Hammond
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ayla Humphrey
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | | | - Nicola Morant
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Lee Shepstone
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Erika Sims
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Patrick Smith
- Department of Psychology, King's College London Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | | | - Annie Swanepoel
- Hertfordshire Partnership University NHS Foundation Trust, Hatfield, UK
| | - David Trickey
- Specialist Trauma and Maltreatment Service, Anna Freud National Centre for Children and Families, London, UK
| | - Katie Trigg
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Jon Wilson
- Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | - Richard Meiser-Stedman
- Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK
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Haller G, Chan MTV, Combescure C, Lopez U, Pichon I, Licker M, Fournier R, Myles P. The international ENIGMA-II substudy on postoperative cognitive disorders (ISEP). Sci Rep 2021; 11:11631. [PMID: 34078975 PMCID: PMC8173006 DOI: 10.1038/s41598-021-91014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/12/2021] [Indexed: 11/09/2022] Open
Abstract
There is a large controversy as to whether nitrous oxide (N2O) added to the anaesthetic gas mixture is harmful or harmless for postoperative cognitive function recovery. We performed a nested study in the ENIGMA-II trial and compared postoperative neurocognitive recovery of patients randomly receiving N2O (70%) or Air (70%) in 30% O2 during anesthesia. We included adults having non cardiac surgery. We compared recovery scores for episodic memory, decision making/processing speed and executive functions measured with the computerised Cambridge Neuropsychological Test Automated Battery (CANTAB). Assessments were performed at baseline, seven and ninety days. At first interim analysis, following recruitment of 140 participants, the trial was suspended. We found that the mean (95%CI) changes of scores for episodic memory were in the Pocock futility boundaries. Decision making/processing speed did not differ either between groups (P > 0.182). But for executive functions at seven days, the mean number (95% CI) of problems successfully solved and the number of correct box choices made was higher in the N2O group, P = 0.029. N2O with the limitations of an interim analysis appears to have no harmful effect on cognitive functions (memory/processing speed). It may improve the early recovery process of executive functions. This preliminary finding warrants further investigations.
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Affiliation(s)
- Guy Haller
- Division of Anesthesiology, Department of Acute Care Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, Rue Perret-Gentil, 1211, Genève 14, Switzerland. .,Health Services Management and Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region, China
| | - Christophe Combescure
- Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ursula Lopez
- Unit of Neuropsychology and Logopedics, Department of Medicine, Cantonal Hospital of Fribourg, Fribourg, Switzerland
| | - Isabelle Pichon
- Division of Anesthesiology, Department of Acute Care Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, Rue Perret-Gentil, 1211, Genève 14, Switzerland
| | - Marc Licker
- Division of Anesthesiology, Department of Acute Care Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, Rue Perret-Gentil, 1211, Genève 14, Switzerland
| | - Roxane Fournier
- Division of Anesthesiology, Department of Acute Care Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, Rue Perret-Gentil, 1211, Genève 14, Switzerland
| | - Paul Myles
- Department of Anesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
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Watt HC. Reflection on modern methods: Statistics education beyond 'significance': novel plain English interpretations to deepen understanding of statistics and to steer away from misinterpretations. Int J Epidemiol 2021; 49:2083-2088. [PMID: 32710113 DOI: 10.1093/ije/dyaa080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2020] [Indexed: 11/14/2022] Open
Abstract
Concerns have been expressed over standards of statistical interpretation. Results with P <0.05 are often referred to as 'significant' which, in plain English, implies important. This leads some people directly into the misconception that this provides proof that associations are clinically relevant. There are calls for statistics educators to respond to these concerns. This article provides novel plain English interpretations that are designed to deepen understanding. Experience teaching postgraduates at Imperial College is discussed. A key issue with focusing on 'significance' is the common inappropriate practice of implying no association exists, simply because P >0.05. Referring to strengths of association in 'study participants' gives them gravitas, which may help to avoid this. This contrasts with the common practice of focusing on imprecision, by referring to the 'sample' and to 'point estimates'. Unlike formal statistical definitions, interpretations developed and presented here are rooted in the application of statistics. They are based on one set of study participants (not many random samples). Precision of strengths of association are based on using strengths in study participants to estimate strengths of association in the population (from which participants were selected by probability random sampling). Reference to 'compatibility with study data, dependent on statistical modelling assumptions' reminds us of the importance of data quality and modelling assumptions. A straightforward graph shows the relationship between P-values and test statistics. This figure and associated interpretations were developed to illuminate the continuous nature of P-values. This is designed to discourage focus on whether P <0.05, and encourage interpretation of exact P-values.
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Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med 2021; 47:653-664. [PMID: 34032882 PMCID: PMC8144872 DOI: 10.1007/s00134-021-06417-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022]
Abstract
Purpose The effect of the routine use of a stylet during tracheal intubation on first-attempt intubation success is unclear. We hypothesised that the first-attempt intubation success rate would be higher with tracheal tube + stylet than with tracheal tube alone. Methods In this multicentre randomised controlled trial, conducted in 32 intensive care units, we randomly assigned patients to tracheal tube + stylet or tracheal tube alone (i.e. without stylet). The primary outcome was the proportion of patients with first-attempt intubation success. The secondary outcome was the proportion of patients with complications related to tracheal intubation. Serious adverse events, i.e., traumatic injuries related to tracheal intubation, were evaluated. Results A total of 999 patients were included in the modified intention-to-treat analysis: 501 (50%) to tracheal tube + stylet and 498 (50%) to tracheal tube alone. First-attempt intubation success occurred in 392 patients (78.2%) in the tracheal tube + stylet group and in 356 (71.5%) in the tracheal tube alone group (absolute risk difference, 6.7; 95%CI 1.4–12.1; relative risk, 1.10; 95%CI 1.02–1.18; P = 0.01). A total of 194 patients (38.7%) in the tracheal tube + stylet group had complications related to tracheal intubation, as compared with 200 patients (40.2%) in the tracheal tube alone group (absolute risk difference, − 1.5; 95%CI − 7.5 to 4.6; relative risk, 0.96; 95%CI 0.83–1.12; P = 0.64). The incidence of serious adverse events was 4.0% and 3.6%, respectively (absolute risk difference, 0.4; 95%CI, − 2.0 to 2.8; relative risk, 1.10; 95%CI 0.59–2.06. P = 0.76). Conclusions Among critically ill adults undergoing tracheal intubation, using a stylet improves first-attempt intubation success. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06417-y.
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Schandelmaier S, Briel M, Varadhan R, Schmid CH, Devasenapathy N, Hayward RA, Gagnier J, Borenstein M, van der Heijden GJMG, Dahabreh IJ, Sun X, Sauerbrei W, Walsh M, Ioannidis JPA, Thabane L, Guyatt GH. Development of the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN) in randomized controlled trials and meta-analyses. CMAJ 2021; 192:E901-E906. [PMID: 32778601 DOI: 10.1503/cmaj.200077] [Citation(s) in RCA: 244] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most randomized controlled trials (RCTs) and meta-analyses of RCTs examine effect modification (also called a subgroup effect or interaction), in which the effect of an intervention varies by another variable (e.g., age or disease severity). Assessing the credibility of an apparent effect modification presents challenges; therefore, we developed the Instrument for assessing the Credibility of Effect Modification Analyses (ICEMAN). METHODS To develop ICEMAN, we established a detailed concept; identified candidate credibility considerations in a systematic survey of the literature; together with experts, performed a consensus study to identify key considerations and develop them into instrument items; and refined the instrument based on feedback from trial investigators, systematic review authors and journal editors, who applied drafts of ICEMAN to published claims of effect modification. RESULTS The final instrument consists of a set of preliminary considerations, core questions (5 for RCTs, 8 for meta-analyses) with 4 response options, 1 optional item for additional considerations and a rating of credibility on a visual analogue scale ranging from very low to high. An accompanying manual provides rationales, detailed instructions and examples from the literature. Seventeen potential users tested ICEMAN; their suggestions improved the user-friendliness of the instrument. INTERPRETATION The Instrument for assessing the Credibility of Effect Modification Analyses offers explicit guidance for investigators, systematic reviewers, journal editors and others considering making a claim of effect modification or interpreting a claim made by others.
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Affiliation(s)
- Stefan Schandelmaier
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont.
| | - Matthias Briel
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Ravi Varadhan
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Christopher H Schmid
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Niveditha Devasenapathy
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Rodney A Hayward
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Joel Gagnier
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Michael Borenstein
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Geert J M G van der Heijden
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Issa J Dahabreh
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Xin Sun
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Willi Sauerbrei
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Michael Walsh
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - John P A Ioannidis
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Lehana Thabane
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
| | - Gordon H Guyatt
- Departments of Health Research Methods, Evidence, and Impact (Schandelmaier, Briel, Walsh, Thabane, Guyatt), Medicine (Walsh, Guyatt), Pediatrics (Thabane) and Anesthesia (Thabane), McMaster University, Hamilton, Ont.; Institute for Clinical Epidemiology and Biostatistics (Schandelmaier, Briel), Department of Clinical Research, Basel University, Basel, Switzerland; Division of Biostatistics and Bioinformatics (Varadhan), Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Md.; Department of Biostatistics (Schmid), Brown University School of Public Health, Brown University, Providence, RI; Indian institute of Public Health-Delhi (Devasenapathy), Public Health Foundation of India, New Delhi, India; VA Center for Clinical Management and Research (Hayward); Department of Internal Medicine (Hayward), University of Michigan School of Medicine; Department of Orthopaedic Surgery (Gagnier), University of Michigan; Department of Epidemiology (Gagnier), School of Public Health, University of Michigan, Ann Arbor, Mich.; Biostat (Borenstein), Englewood, NJ; Department of Social Dentistry (van der Heijden), Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands; Center for Evidence Synthesis in Health (Dahabreh) and Departments of Health Services, Policy, and Practice (Dahabreh) and Epidemiology (Dahabreh), School of Public Health, Brown University, Providence, RI; Chinese Evidence-Based Medicine Center (Sun), West China Hospital, Sichuan University, Chengdu, China; Institute of Medical Biometry and Statistics (Sauerbrei), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany; Population Health Research Institute (Walsh), Hamilton Health Sciences/McMaster University, Hamilton, Ont.; Departments of Medicine (Ioannidis), Health Research and Policy (Ioannidis) and Biomedical Data Science (Ioannidis), and Statistics and Meta-Research Innovation Center at Stanford (METRICS) (Ioannidis), Stanford University, Stanford, Calif.; Biostatistics Unit (Thabane), St. Joseph's Healthcare, Hamilton, Ont
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82
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Giacoppo D, Alfonso F, Xu B, Claessen BEPM, Adriaenssens T, Jensen C, Pérez-Vizcayno MJ, Kang DY, Degenhardt R, Pleva L, Baan J, Cuesta J, Park DW, Schunkert H, Colleran R, Kukla P, Jiménez-Quevedo P, Unverdorben M, Gao R, Naber CK, Park SJ, Henriques JPS, Kastrati A, Byrne RA. Paclitaxel-coated balloon angioplasty vs. drug-eluting stenting for the treatment of coronary in-stent restenosis: a comprehensive, collaborative, individual patient data meta-analysis of 10 randomized clinical trials (DAEDALUS study). Eur Heart J 2021; 41:3715-3728. [PMID: 31511862 PMCID: PMC7706792 DOI: 10.1093/eurheartj/ehz594] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 06/26/2019] [Accepted: 08/08/2019] [Indexed: 01/10/2023] Open
Abstract
Abstract
Aims
Consensus is lacking regarding the best treatment for coronary in-stent restenosis (ISR). The two most effective treatments are angioplasty with paclitaxel-coated balloon (PCB) and repeat stenting with drug-eluting stent (DES) but individual trials were not statistically powered for clinical endpoints, results were heterogeneous, and evidence about comparative efficacy and safety in relevant subsets was limited.
Methods and results
The Difference in Anti-restenotic Effectiveness of Drug-eluting stent and drug-coated balloon AngiopLasty for the occUrrence of coronary in-Stent restenosis (DAEDALUS) study was a comprehensive, investigator-initiated, collaborative, individual patient data meta-analysis comparing angioplasty with PCB alone vs. repeat stenting with DES alone for the treatment of coronary ISR. The protocol was registered with PROSPERO (CRD42017075007). All 10 available randomized clinical trials were included with 1976 patients enrolled, 1033 assigned to PCB and 943 to DES. At 3-year follow-up, PCB was associated with a significant increase in the risk of target lesion revascularization (TLR) compared with DES [hazard ratio (HR) 1.32, 95% CI 1.02–1.70, P = 0.035; number-needed-to-harm 28.5]. There was a significant interaction between treatment effect and type of restenosed stent (P = 0.029) with a more marked difference in patients with DES-ISR and comparable effects in patients with bare-metal stent-ISR. At 3-year follow-up, the primary safety endpoint of all-cause death, myocardial infarction, or target lesion thrombosis was comparable between treatments (HR 0.80, 95% CI 0.58–1.09, P = 0.152). A pre-specified subgroup analysis indicated a significant interaction between treatment effect and type of DES used to treat ISR (P = 0.033), with a lower incidence of events associated with PCB compared with first-generation DES and similar effect between PCB and second-generation DES (HR 1.06, 95% CI 0.71–1.60, P = 0.764). Long-term all-cause mortality was similar between PCB and DES (HR 0.81, 95% CI 0.53–1.22, P = 0.310); results were consistent comparing PCB and non-paclitaxel-based DES (HR 1.42, 95% CI 0.80–2.54, P = 0.235). Myocardial infarction and target lesion thrombosis were comparable between treatments.
Conclusions
In patients with coronary ISR, repeat stenting with DES is moderately more effective than angioplasty with PCB at reducing the need for TLR at 3 years. The incidence of a composite of all-cause death, myocardial infarction, or target lesion thrombosis was similar between groups. The rates of individual endpoints, including all-cause mortality, were not significantly different between groups.
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Affiliation(s)
- Daniele Giacoppo
- Department of Cardiovascular Diseases, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa Madrid, Calle Diego de León 62, Madrid 28006, Spain
| | - Bo Xu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, 167 Beilishi Road, Xicheng, 100037 Beijing, China
| | - Bimmer E P M Claessen
- Mount Sinai Heart, the Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, 10029 New York, NY, USA
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Christoph Jensen
- Department of Cardiology, Contilia Heart and Vascular Center, Elisabeth Krankenhaus, Klara-Kopp-Weg 1, 45138 Essen, Germany
| | - María J Pérez-Vizcayno
- Department of Cardiology, Hospital Clinico San Carlos, Calle Profesor Martin Lagos, 28040 Madrid, Spain
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan, 388-1 Poongnapdong, Seoul 138-736, South Korea
| | - Ralf Degenhardt
- Department of Cardiology, Herz-Kreislauf-Zentrum, Heinz-Meise-Strasse 100, 36199 Rotenburg an der Fulda, Germany
| | - Leos Pleva
- Department of Cardiology, University Hospital Ostrava, tr. 17 listopadu 1790, 70852 Ostrava, Czech Republic
| | - Jan Baan
- Department of Cardiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Javier Cuesta
- Department of Cardiology, Hospital Universitario de La Princesa Madrid, Calle Diego de León 62, Madrid 28006, Spain
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan, 388-1 Poongnapdong, Seoul 138-736, South Korea
| | - Heribert Schunkert
- Department of Cardiovascular Diseases, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Roisin Colleran
- Department of Cardiovascular Diseases, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany
| | - Pavel Kukla
- Department of Cardiology, University Hospital Ostrava, tr. 17 listopadu 1790, 70852 Ostrava, Czech Republic
| | - Pilar Jiménez-Quevedo
- Department of Cardiology, Hospital Clinico San Carlos, Calle Profesor Martin Lagos, 28040 Madrid, Spain
| | - Martin Unverdorben
- Department of Cardiology, Herz-Kreislauf-Zentrum, Heinz-Meise-Strasse 100, 36199 Rotenburg an der Fulda, Germany.,Daiichi Sankyo, 211 Mt. Airy Road, 07920 Basking Ridge, NJ, USA
| | - Runlin Gao
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, 167 Beilishi Road, Xicheng, 100037 Beijing, China
| | - Christoph K Naber
- Department of Cardiology, Contilia Heart and Vascular Center, Elisabeth Krankenhaus, Klara-Kopp-Weg 1, 45138 Essen, Germany
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan, 388-1 Poongnapdong, Seoul 138-736, South Korea
| | - José P S Henriques
- Department of Cardiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Adnan Kastrati
- Department of Cardiovascular Diseases, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Robert A Byrne
- Department of Cardiovascular Diseases, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
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83
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Yang S, Lorenzi E, Papadogeorgou G, Wojdyla DM, Li F, Thomas LE. Propensity score weighting for causal subgroup analysis. Stat Med 2021; 40:4294-4309. [PMID: 33982316 PMCID: PMC8360075 DOI: 10.1002/sim.9029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/20/2021] [Accepted: 04/25/2021] [Indexed: 01/08/2023]
Abstract
A common goal in comparative effectiveness research is to estimate treatment effects on prespecified subpopulations of patients. Though widely used in medical research, causal inference methods for such subgroup analysis (SGA) remain underdeveloped, particularly in observational studies. In this article, we develop a suite of analytical methods and visualization tools for causal SGA. First, we introduce the estimand of subgroup weighted average treatment effect and provide the corresponding propensity score weighting estimator. We show that balancing covariates within a subgroup bounds the bias of the estimator of subgroup causal effects. Second, we propose to use the overlap weighting (OW) method to achieve exact balance within subgroups. We further propose a method that combines OW and LASSO, to balance the bias‐variance tradeoff in SGA. Finally, we design a new diagnostic graph—the Connect‐S plot—for visualizing the subgroup covariate balance. Extensive simulation studies are presented to compare the proposed method with several existing methods. We apply the proposed methods to the patient‐centered results for uterine fibroids (COMPARE‐UF) registry data to evaluate alternative management options for uterine fibroids for relief of symptoms and quality of life.
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Affiliation(s)
- Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Fan Li
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
| | - Laine E Thomas
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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84
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Bentley JP, Ramachandran S, Salgado TM. Considerations when conducting moderation analysis with a binary outcome: Applications to clinical and social pharmacy research. Res Social Adm Pharm 2021; 18:2276-2282. [PMID: 34119445 DOI: 10.1016/j.sapharm.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/02/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
Clinical and social pharmacy researchers often have questions regarding contingencies of effects (i.e., moderation) that are tested by including interactions in statistical models. Much of the available literature for estimating and testing effects that emanate from moderation models is based on extensions of the linear model with continuous outcomes. Binary (or dichotomous) outcome variables, such as prescription-medication misuse versus no misuse, are commonly encountered by clinical and social pharmacy researchers. In moderation analysis, binary outcomes have led to an increased focus on the fact that measures of interaction are scale-dependent; thus, researchers may need to consider both additive interaction and multiplicative interaction. Further complicating interpretation is that the statistical model chosen for an interaction can provide different answers to questions of moderation. This manuscript will: 1) identify research questions in clinical and social pharmacy that necessitate the use of these statistical methods, 2) review statistical models that can be used to estimate effects when the outcome of interest is binary, 3) review basic concepts of moderation, 4) describe the challenges inherent in conducting moderation analysis when modeling binary outcomes, and 5) demonstrate how to conduct such analyses and interpret relevant statistical output (including interpretations of interactions on additive and multiplicative scales with a focus on identifying which statistical models for binary outcomes lead to which measure of interaction). Although much of the basis for this paper comes from research in epidemiology, recognition of these issues has occurred in other disciplines.
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Affiliation(s)
- John P Bentley
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, Faser Hall, University, MS, 38677, USA.
| | - Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, Faser Hall, University, MS, 38677, USA
| | - Teresa M Salgado
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N 12th Street, P.O. Box 980533, Richmond, VA, 23298-0533, USA
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85
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Riberholt CG, Olsen MH, Søndergaard CB, Gluud C, Ovesen C, Jakobsen JC, Mehlsen J, Møller K. Early Orthostatic Exercise by Head-Up Tilt With Stepping vs. Standard Care After Severe Traumatic Brain Injury Is Feasible. Front Neurol 2021; 12:626014. [PMID: 33935935 PMCID: PMC8079637 DOI: 10.3389/fneur.2021.626014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Intensive rehabilitation of patients after severe traumatic brain injury aims to improve functional outcome. The effect of initiating rehabilitation in the early phase, in the form of head-up mobilization, is unclear. Objective: To assess whether early mobilization is feasible and safe in patients with traumatic brain injury admitted to a neurointensive care unit. Methods: This was a randomized parallel-group clinical trial, including patients with severe traumatic brain injury (Glasgow coma scale <11 and admission to the neurointensive care unit). The intervention consisted of daily mobilization on a tilt-table for 4 weeks. The control group received standard care. Outcomes were the number of included participants relative to all patients with traumatic brain injury who were approached for inclusion, the number of conducted mobilization sessions relative to all planned sessions, as well as adverse events and reactions. Information on clinical outcome was collected for exploratory purposes. Results: Thirty-eight participants were included (19 in each group), corresponding to 76% of all approached patients [95% confidence interval (CI) 63–86%]. In the intervention group, 74% [95% CI 52–89%] of planned sessions were carried out. There was no difference in the number of adverse events, serious adverse events, or adverse reactions between the groups. Conclusions: Early head-up mobilization is feasible in patients with severe traumatic brain injury. Larger randomized clinical trials are needed to explore potential benefits and harms of such an intervention. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02924649]. Registered on 3rd October 2016.
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Affiliation(s)
- Christian Gunge Riberholt
- Traumatic Brain Injury Unit, Department of Neurorehabilitation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Gluud
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Ovesen
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Neurology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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86
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Zhu H, Xu X, Fang X, Ying F, Song L, Gao B, Tong G, Zhou L, Chen T, Huang J. Efficacy and Safety of Long-Term Antithrombotic Strategies in Patients With Chronic Coronary Syndrome: A Network Meta-analysis of Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e019184. [PMID: 33682435 PMCID: PMC8174196 DOI: 10.1161/jaha.120.019184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Long-term antithrombotic strategies for patients with chronic coronary syndrome with high-risk factors represent an important treatment dilemma in clinical practice. Our aim was to conduct a network meta-analysis to evaluate the efficacy and safety of long-term antithrombotic strategies in patients with chronic coronary syndrome. Methods and Results Four randomized studies were included (n=75167; THEMIS [Ticagrelor on Health Outcomes in Diabetes Mellitus Patients Intervention Study], COMPASS [Cardiovascular Outcomes for People Using Anticoagulation Strategies], PEGASUS-TIMI 54 [Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54], and DAPT [Dual Anti-platelet Therapy]). The odds ratios (ORs) and 95% CIs) were calculated as the measure of effect size. The results of the network meta-analysis showed that, compared with aspirin monotherapy, the ORs for trial-defined major adverse cardiovascular and cerebrovascular events were 0.86; (95% CI, 0.80-0.93) for ticagrelor plus aspirin, 0.89 (95% CI, 0.78-1.02) for rivaroxaban monotherapy, 0.74 (95% CI, 0.64-0.85) for rivaroxaban plus aspirin, and 0.72 (95% CI, 0.60,-0.86) for thienopyridine plus aspirin. Compared with aspirin monotherapy, the ORs for trial-defined major bleeding were 2.15 (95% CI, 1.78-2.59]) for ticagrelor plus aspirin, 1.51 (95% CI, 1.23-1.85) for rivaroxaban monotherapy, and 1.68 (95% CI, 1.37-2.05) for rivaroxaban plus aspirin. For death from any cause, the improvement effect of rivaroxaban plus aspirin was detected versus aspirin monotherapy (OR, 0.76; 95% CI, 0.65-0.90), ticagrelor plus aspirin (OR, 0.79; 95% CI, 0.66-0.95), rivaroxaban monotherapy (OR, 0.82; 95% CI, 0.69-0.97), and thienopyridine plus aspirin (OR, 0.58; 95% CI, 0.41-0.82) regimens. Conclusions All antithrombotic strategies combined with aspirin significantly reduced the incidence of major adverse cardiovascular and cerebrovascular events and increased the risk of major bleeding compared with aspirin monotherapy. Considering the outcomes of all ischemic and bleeding events and all-cause mortality, rivaroxaban plus aspirin appears to be the preferred long-term antithrombotic regimen for patients with chronic coronary syndrome and high-risk factors.
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Affiliation(s)
- Houyong Zhu
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Xiaoqun Xu
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine Zhejiang China
| | - Xiaojiang Fang
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Fei Ying
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Liuguang Song
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Beibei Gao
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
| | - Guoxin Tong
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
| | - Liang Zhou
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
| | - Tielong Chen
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Jinyu Huang
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
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87
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Huang Y, Cho J, Fong Y. Threshold-based subgroup testing in logistic regression models in two-phase sampling designs. J R Stat Soc Ser C Appl Stat 2021; 70:291-311. [PMID: 33840863 PMCID: PMC8032557 DOI: 10.1111/rssc.12459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The effect of treatment on binary disease outcome can differ across subgroups characterized by other covariates. Testing for the existence of subgroups that are associated with heterogeneous treatment effects can provide valuable insight regarding the optimal treatment recommendation in practice. Our research in this paper is motivated by the question of whether host genetics could modify a vaccine's effect on HIV acquisition risk. To answer this question, we used data from an HIV vaccine trial with a two-phase sampling design and developed a general threshold-based model framework to test for the existence of subgroups associated with the heterogeneity in disease risks, allowing for subgroups based on multivariate covariates. We developed a testing procedure based on maximum of likelihood-ratio statistics over change planes and demonstrated its advantage over alternative methods. We further developed the testing procedure to account for bias sampling of expensive (i.e. resource-intensive to measure) covariates through the incorporation of inverse probability weighting techniques. We used the proposed method to analyze the motivating HIV vaccine trial data. Our proposed testing procedure also has broad applications in epidemiological studies for assessing heterogeneity in disease risk with respect to univariate or multivariate predictors.
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Affiliation(s)
- Ying Huang
- Biostatistics, Bioinformatics, & Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109
| | - Juhee Cho
- Biostatistics, Bioinformatics, & Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109
| | - Youyi Fong
- Biostatistics, Bioinformatics, & Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109
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88
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Wu C, Newman D, Schwartz TA, Zou B, Miller J, Palmer MH. Effects of unsupervised behavioral and pelvic floor muscle training programs on nocturia, urinary urgency, and urinary frequency in postmenopausal women: Secondary analysis of a randomized, two-arm, parallel design, superiority trial (TULIP study). Maturitas 2021; 146:42-48. [PMID: 33722363 DOI: 10.1016/j.maturitas.2021.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine and compare the effects of an unsupervised behavioral and pelvic floor muscle training (B-PFMT) program delivered in two formats on nocturia, urinary urgency, and urinary frequency in postmenopausal women. STUDY DESIGN A secondary analysis used data collected from women enrolled in the TULIP study. Women aged 55 years or more with no urinary incontinence were provided the B-PFMT program. Each woman was randomly assigned to a face-to-face class that took about 2 h (2-hrClass) or to a DVD showing essentially the same information as a 20-minute video (20-minVideo). All women were instructed to independently continue the program following their education session. Three urinary outcomes were assessed at baseline, 3, 12, and 24 months. MAIN OUTCOME MEASURES Nocturia and urinary urgency were examined with one item each from the questionnaire-based voiding diary, and urinary frequency was assessed with patients' self-documenting 3-day bladder diary. RESULTS Women in the 2-hrClass group experienced significantly fewer nocturia episodes and longer average inter-void interval at each follow-up and fewer urinary urgency episodes at 12 months. Women in the 20-minVideo group experienced significantly fewer episodes of nocturia and urinary urgency and longer average inter-void interval at each follow-up time point. No significant between-group differences were found for any outcome, except for nocturia at 24 months, when effectiveness favored women in the 20-minVideo group. CONCLUSIONS Unsupervised B-PFMT programs are effective for improving postmenopausal women's urinary outcomes regardless of the format. The optimal format to deliver B-PFMT programs in terms of effectiveness should be explored in future studies.
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Affiliation(s)
- Chen Wu
- University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, United States
| | - Diane Newman
- University of Pennsylvania, Perelman School of Medicine, Division of Urology, Department of Surgery, Philadelphia, PA, United States
| | - Todd A Schwartz
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Biostatistics, School of Nursing, Chapel Hill, NC, United States
| | - Baiming Zou
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Biostatistics, School of Nursing, Chapel Hill, NC, United States
| | - Janis Miller
- University of Michigan, School of Nursing, Ann Arbor, MI, United States
| | - Mary H Palmer
- Helen W. & Thomas L. Umphlet Distinguished Professor in Aging, University of North Carolina at Chapel Hill, School of Nursing, CB 7460, Chapel Hill, NC 27599-7460, United States.
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89
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Shah VN, Franek E, Wernicke-Panten K, Pierre S, Mukherjee B, Sadeharju K. Efficacy, Safety, and Immunogenicity of Insulin Aspart Biosimilar SAR341402 Compared with Originator Insulin Aspart in Adults with Diabetes (GEMELLI 1): A Subgroup Analysis by Prior Type of Mealtime Insulin. Diabetes Ther 2021; 12:557-568. [PMID: 33432547 PMCID: PMC7846644 DOI: 10.1007/s13300-020-00992-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/19/2020] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION The biosimilar SAR341402 insulin aspart (SAR-Asp) was compared to its originator NovoLog®/NovoRapid® insulin aspart (NN-Asp) in terms of efficacy, safety, and immunogenicity, in adults with type 1 or type 2 diabetes switching from different rapid-acting insulin analogs. METHODS This phase 3, randomized, open-label, multinational, 52-week study (GEMELLI 1) enrolled participants with type 1 or type 2 diabetes (n = 597). At randomization, participants transitioned from NovoLog/NovoRapid (n = 380) or Humalog®/Liprolog® (n = 217) to equivalent (1:1) doses (or a dose at the discretion of the investigator) of either SAR-Asp or NN-Asp (1:1 randomization). Participants were treated with multiple daily injections in combination with insulin glargine 100 U/mL (Lantus®). In this subgroup analysis, efficacy measures (change in hemoglobin A1c [HbA1c], insulin dose [total, basal and mealtime]), and safety outcomes (hypoglycemia incidence, adverse events, anti-insulin aspart antibodies) of SAR-Asp were compared with those of NN-Asp separately according to the participants' prestudy mealtime insulin. RESULTS At week 26 (primary efficacy endpoint), change in HbA1c was similar between SAR-Asp and NN-Asp in those participants pre-treated with NovoLog/NovoRapid (least squares [LS] mean difference - 0.04%, 95% confidence interval [CI] - 0.182 to 0.106%) or Humalog/Liprolog (LS mean difference - 0.15%, 95% CI - 0.336 to 0.043%) (P value for treatment by subgroup interaction = 0.36). This HbA1c response persisted over the 52 weeks of the study similarly for both treatments within each subgroup. In both subgroups, changes in insulin doses were similar between treatments over 26 weeks and 52 weeks, as were the incidences of severe or any hypoglycemia, adverse events (including hypersensitivity and injection site reactions), and anti-insulin aspart antibodies. CONCLUSIONS Efficacy and safety (including immunogenicity) profiles of SAR-Asp are similar to those of NN-Asp over 52 weeks in adults with diabetes irrespective of prior type of mealtime insulin. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03211858.
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Affiliation(s)
- Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Edward Franek
- Mossakowski Clinical Research Centre, Polish Academy of Sciences, Warsaw, Poland
- Central Clinical Hospital of the Ministry of Interior and Administration (CSK MSWiA), Warsaw, Poland
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90
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Brand KJ, Hapfelmeier A, Haller B. A systematic review of subgroup analyses in randomised clinical trials in cardiovascular disease. Clin Trials 2021; 18:351-360. [PMID: 33478253 PMCID: PMC8174013 DOI: 10.1177/1740774520984866] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Subgroup analyses are frequently used to assess heterogeneity of treatment effects in randomised clinical trials. Inconsistent, improper and incomplete implementation, reporting and interpretation have been identified as ongoing challenges. Further, subgroup analyses were frequently criticised because of unreliable or potentially misleading results. More recently, recommendations and guidelines have been provided to improve the reporting of data in this regard. Methods: This systematic review was based on a literature search within the digital archives of three selected medical journals, The New England Journal of Medicine, The Lancet and Circulation. We reviewed articles of randomised clinical trials in the domain of cardiovascular disease which were published in 2015 and 2016. We screened and evaluated the selected articles for the mode of implementation and reporting of subgroup analyses. Results: We were able to identify a total of 130 eligible publications of randomised clinical trials. In 89/130 (68%) articles, results of at least one subgroup analysis were presented. This was dependent on the considered journal (p < 0.001), the number of included patients (p < 0.001) and the lack of statistical significance of a trial’s primary analysis (p < 0.001). The number of reported subgroup analyses ranged from 1 to 101 (median = 13). We were able to comprehend the specification time of reported subgroup analyses for 71/89 (80%) articles, with 55/89 (62%) articles presenting exclusively pre-specified analyses. This information was not always traceable on the basis of provided trial protocols and often did not include the pre-definition of cut-off values for the categorization of subgroups. The use of interaction tests was reported in 84/89 (94%) articles, with 36/89 (40%) articles reporting heterogeneity of the treatment effect for at least one primary or secondary trial outcome. Subgroup analyses were reported more frequently for larger randomised clinical trials, and if primary analyses did not reach statistical significance. Information about the implementation of subgroup analyses was reported most consistently for articles from The New England Journal of Medicine, since it was also traceable on the basis of provided trial protocols. We were able to comprehend whether subgroup analyses were pre-specified in a majority of the reviewed publications. Even though results of multiple subgroup analyses were reported for most published trials, a corresponding adjustment for multiple testing was rarely considered. Conclusion: Compared to previous reviews in this context, we observed improvements in the reporting of subgroup analyses of cardiovascular randomised clinical trials. Nonetheless, critical shortcomings, such as inconsistent reporting of the implementation and insufficient pre-specification, persist.
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Affiliation(s)
- Korbinian J Brand
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany.,Institute of General Practice and Health Services Research, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
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91
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Wu CY, Rodakowski J, Terhorst L, Dew MA, Butters M, Karp JF, Albert SM, Gildengers AG, Reynolds CF, Skidmore ER. Frequency of But Not Capacity for Participation in Everyday Activities Is Associated With Cognitive Impairment in Late Life. J Appl Gerontol 2021; 40:1579-1586. [PMID: 33406968 DOI: 10.1177/0733464820984283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We examined features of everyday activities (capacity and frequency) between older adults with and without cognitive impairment over 12 months. Participants aged ≥60 years and at risk for depression were included (n = 260); 26% (n = 69) had an acquired cognitive impairment at baseline. Cognitive impairment was defined as one standard deviation below norms on the Repeatable Battery for the Assessment of Neuropsychological Status. Features of everyday activities were measured by a computerized adaptive test version of Late-Life Function and Disability Instrument (LLFDI) at six time points (baseline, 6 weeks, 3, 6, 9, 12 months). There were significant between-group differences in activity frequency (p = .04), but not activity capacity (p = .05). The group difference in activity frequency exceeded minimal detectable changes (MDC90 = 3.7) and reached moderate clinical meaningfulness (∆ at six time points = 3.7-4.7). Generalized linear mixed models revealed no Group × Time interactions on activity capacity and frequency (p = .65 and p = .98). Practitioners may assess changes in activity frequency to monitor cognitive status of clients even when there is no loss of activity capacity.
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Affiliation(s)
- Chao-Yi Wu
- Department of Neurology, Oregon Health & Science University School of Medicine, OR, USA
| | - Juleen Rodakowski
- Department of Occupational Therapy, Univeristy of Pittsburgh School of Health and Rehabilitation Sciences, PA, USA.,Clinical and Translational Institute, University of Pittsburgh, PA, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, Univeristy of Pittsburgh School of Health and Rehabilitation Sciences, PA, USA.,Clinical and Translational Institute, University of Pittsburgh, PA, USA.,Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Mary Amanda Dew
- Clinical and Translational Institute, University of Pittsburgh, PA, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.,Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Meryl Butters
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Ariel G Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elizabeth R Skidmore
- Department of Occupational Therapy, Univeristy of Pittsburgh School of Health and Rehabilitation Sciences, PA, USA.,Clinical and Translational Institute, University of Pittsburgh, PA, USA.,Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
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92
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Báez-Gutiérrez N, Rodríguez-Ramallo H, Flores-Moreno S, Abdel-Kader Martín L. Subgroup analysis in haematologic malignancies phase III clinical trials: A systematic review. Br J Clin Pharmacol 2020; 87:2635-2644. [PMID: 33270263 DOI: 10.1111/bcp.14689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/02/2020] [Accepted: 11/24/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS To assess the appropriateness of the use and interpretation of subgroup analysis in haematology randomized clinical trials (RCTs). METHOD A systematic review of Medline, including haematology phase III RCTs published between January 2013 and October 2019, was carried out to identify reported subgroup analysis. Information related to trial characteristics, subgroup analysis and claims of subgroup difference were collected. RESULTS The initial search identified 1622 studies. A total of 98 studies reporting subgroup analyses were identified. Of those, 24 RCT reported 46 claims of subgroup difference. Among them, 44 were claims for the primary outcome, of which 25 were considered strong claims and 17 were considered suggestions of a possible effect. Authors included subgroup variables for the primary outcome measured at baseline for 38 claims (n = 86.36%), used a subgroup variable as a stratification factor at randomization for 15 (34.09%), clearly prespecified their hypothesis for 11 (25%), the subgroup effect was one of a small number of hypothesised effects tested (≤ 5) for 17 (38.64%), carried out a test of interaction that provide statistically significant for 18 (40.91%), documented replication of a subgroup effect with previously related studies for 11 (25%), identified the consistency of a subgroup effect across related outcome for 10 (22.72%) and provided a biological rationale for the effect for 8 (18.18%). Of the 44 claims for the primary outcome, 34 (77.27%) met four or fewer of the 10 credibility criteria. CONCLUSION The subgroup claims reported in haematology RCTs lack credibility, even when the claims are strong. Information about subgroup difference should be interpreted cautiously.
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Affiliation(s)
- Nerea Báez-Gutiérrez
- Hospital Pharmacy Department, Virgen del Rocio University Hospital, Seville, Spain
| | | | - Sandra Flores-Moreno
- Hospital Pharmacy Department, Virgen del Rocio University Hospital, Seville, Spain
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93
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Genitsaridi E, Hoare DJ, Kypraios T, Hall DA. A Review and a Framework of Variables for Defining and Characterizing Tinnitus Subphenotypes. Brain Sci 2020; 10:E938. [PMID: 33291859 PMCID: PMC7762072 DOI: 10.3390/brainsci10120938] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 02/07/2023] Open
Abstract
Tinnitus patients can present with various characteristics, such as those related to the tinnitus perception, symptom severity, and pattern of comorbidities. It is speculated that this phenotypic heterogeneity is associated with differences in the underlying pathophysiology and personal reaction to the condition. However, there is as yet no established protocol for tinnitus profiling or subtyping, hindering progress in treatment development. This review summarizes data on variables that have been used in studies investigating phenotypic differences in subgroups of tinnitus, including variables used to both define and compare subgroups. A PubMed search led to the identification of 64 eligible articles. In most studies, variables for subgrouping were chosen by the researchers (hypothesis-driven approach). Other approaches included application of unsupervised machine-learning techniques for the definition of subgroups (data-driven), and subgroup definition based on the response to a tinnitus treatment (treatment response). A framework of 94 variable concepts was created to summarize variables used across all studies. Frequency statistics for the use of each variable concept are presented, demonstrating those most and least commonly assessed. This review highlights the high dimensionality of tinnitus heterogeneity. The framework of variables can contribute to the design of future studies, helping to decide on tinnitus assessment and subgrouping.
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Affiliation(s)
- Eleni Genitsaridi
- Hearing Sciences, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (D.J.H.); (D.A.H.)
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham NG1 5DU, UK
| | - Derek J. Hoare
- Hearing Sciences, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (D.J.H.); (D.A.H.)
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham NG1 5DU, UK
| | - Theodore Kypraios
- School of Mathematical Sciences, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Deborah A. Hall
- Hearing Sciences, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (D.J.H.); (D.A.H.)
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham NG1 5DU, UK
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- University of Nottingham Malaysia, Semenyih 43500, Selangor Darul Ehsan, Malaysia
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94
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Taylor A, Thompson TP, Ussher M, Aveyard P, Murray RL, Harris T, Creanor S, Green C, Streeter AJ, Chynoweth J, Ingram W, Greaves CJ, Hancocks H, Snowsill T, Callaghan L, Price L, Horrell J, King J, Gude A, George M, Wahlich C, Hamilton L, Cheema K, Campbell S, Preece D. Randomised controlled trial of tailored support to increase physical activity and reduce smoking in smokers not immediately ready to quit: protocol for the Trial of physical Activity-assisted Reduction of Smoking (TARS) Study. BMJ Open 2020; 10:e043331. [PMID: 33262194 PMCID: PMC7709511 DOI: 10.1136/bmjopen-2020-043331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/28/2020] [Accepted: 10/27/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Smoking reduction can lead to increased success in quitting. This study aims to determine if a client-focused motivational support package for smoking reduction (and quitting) and increasing (or otherwise using) physical activity (PA) can help smokers who do not wish to quit immediately to reduce the amount they smoke, and ultimately quit. This paper reports the study design and methods. METHODS AND ANALYSIS A pragmatic, multicentred, parallel, two group, randomised controlled superiority clinical trial, with embedded process evaluation and economics evaluation. Participants who wished to reduce smoking with no immediate plans to quit were randomised 1:1 to receive either (1) tailored individual health trainer face-to-face and/or telephone support to reduce smoking and increase PA as an aid to smoking reduction (intervention) or (2) brief written/electronic advice to reduce or quit smoking (control). Participants in both arms of the trial were also signposted to usual local support for smoking reduction and quitting. The primary outcome measure is 6-month carbon monoxide-confirmed floating prolonged abstinence following participant self-reported quitting on a mailed questionnaire at 3 and 9 months post-baseline. Participants confirmed as abstinent at 9 months will be followed up at 15 months. ETHICS AND DISSEMINATION Approved by SW Bristol National Health Service Research Committee (17/SW/0223). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals. Results will be disseminated to trial participants and healthcare providers. TRIAL REGISTRATION NUMBER ISRCTN47776579; Pre-results.
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Affiliation(s)
- Adrian Taylor
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Tom P Thompson
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Michael Ussher
- Division of Population Health Sciences and Education, University of London, St George's, London, UK
- Institute for Social Marketing, University of Stirling, Stirling, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Division of Public Health and Primary Health Care, Oxford, UK
| | | | - Tess Harris
- Division of Population Health Sciences and Education, University of London, St George's, London, UK
| | - Siobhan Creanor
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Colin Green
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Jade Chynoweth
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Wendy Ingram
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Science, University of Birmingham, Birmingham, UK
| | - Helen Hancocks
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Tristan Snowsill
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Lynne Callaghan
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Lisa Price
- Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Jane Horrell
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Jennie King
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Alex Gude
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Mary George
- Division of Population Health Sciences and Education, University of London, St George's, London, UK
| | - Charlotte Wahlich
- Division of Population Health Sciences and Education, University of London, St George's, London, UK
| | - Louisa Hamilton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Division of Public Health and Primary Health Care, Oxford, UK
| | - Kelisha Cheema
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Sarah Campbell
- School of Medicine, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Dan Preece
- Public Health, Plymouth City Council, Windsor House, Plymouth, Devon, UK
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95
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Kristoffersen PM, Bråten LCH, Vetti N, Grøvle L, Hellum C, Storheim K, Zwart JA, Assmus J, Espeland A. Oedema on STIR modified the effect of amoxicillin as treatment for chronic low back pain with Modic changes-subgroup analysis of a randomized trial. Eur Radiol 2020; 31:4285-4297. [PMID: 33247344 PMCID: PMC8128743 DOI: 10.1007/s00330-020-07542-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/23/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Objective To evaluate potential MRI-defined effect modifiers of amoxicillin treatment in patients with chronic low back pain and type 1 or 2 Modic changes (MCs) at the level of a previous lumbar disc herniation (index level). Methods In a prospective trial (AIM), 180 patients (25–64 years; mean age 45; 105 women) were randomised to receive amoxicillin or placebo for 3 months. Primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (0–24 scale) at 1 year. Mean RMDQ score difference between the groups at 1 year defined the treatment effect; 4 RMDQ points defined the minimal clinically important effect. Predefined baseline MRI features of MCs at the index level(s) were investigated as potential effect modifiers. The predefined primary hypothesis was a better effect of amoxicillin when short tau inversion recovery (STIR) shows more MC-related high signal. To evaluate this hypothesis, we pre-constructed a composite variable with three categories (STIR1/2/3). STIR3 implied MC-related STIR signal increases with volume ≥ 25% and height > 50% of vertebral body and maximum intensity increase ≥ 25% and presence on both sides of the disc. As pre-planned, interaction with treatment was analysed using ANCOVA in the per protocol population (n = 155). Results The STIR3 composite group (n = 41) and STIR signal volume ≥ 25% alone (n = 45) modified the treatment effect of amoxicillin. As hypothesised, STIR3 patients reported the largest effect (− 5.1 RMDQ points; 95% CI − 8.2 to − 1.9; p for interaction = 0.008). Conclusions Predefined subgroups with abundant MC-related index-level oedema on STIR modified the effect of amoxicillin. This finding needs replication and further support. Key Points • In the primary analysis of the AIM trial, the effect of amoxicillin in patients with chronic low back pain and type 1 or 2 MCs did not reach the predefined cut-off for clinical importance. • In the present MRI subgroup analysis of AIM, predefined subgroups with abundant MC-related oedema on STIR reported an effect of amoxicillin. • This finding requires replication and further support. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-020-07542-w.
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Affiliation(s)
- Per Martin Kristoffersen
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
| | - Lars C H Bråten
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956, 0424, Oslo, Nydalen, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, P.O. Box 300, 1714, Grålum, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956, 0424, Oslo, Nydalen, Norway.,Faculty of Health Science, OsloMet - Oslo Metropolitan University, P.O. Box 4, St. Olavs plass, 0130, Oslo, Norway
| | - John-Anker Zwart
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956, 0424, Oslo, Nydalen, Norway.,Faculty of Medicine, University of Oslo, P.O. Box 1072, Blindern, 0316, Oslo, Norway
| | - Jörg Assmus
- Competence Centre for Clinical Research, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
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96
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Suchting R, Kapoor S, Mathis KB, Ahn H. Changes in Experimental Pain Sensitivity from Using Home-Based Remotely Supervised Transcranial Direct Current Stimulation in Older Adults with Knee Osteoarthritis. PAIN MEDICINE 2020; 21:2676-2683. [PMID: 32869092 DOI: 10.1093/pm/pnaa268] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The present study examined the effects of home-based remotely supervised transcranial direct current stimulation on quantitative sensory testing measurements in older adults with knee osteoarthritis. Participants were hypothesized to experience improved pain measurements over time. DESIGN Open-label, single-arm trial. SETTING Southeast Texas between March and November 2018 at a nursing school and participant homes. SUBJECTS Older adults (aged 50-85 years) with self-reported unilateral or bilateral knee osteoarthritis pain who met eligibility criteria set by the American College of Rheumatology. METHODS The intervention was applied with a constant current intensity for 20 minutes every weekday for two weeks (10 total sessions). Quantitative measures of pain were collected three times over 10 days (days 1, 5, and 10) and included heat threshold and tolerance, pressure pain threshold, punctate mechanical pain, pain, and conditioned pain modulation. Analyses used nonparametric tests to evaluate differences between day 1 and day 10. Generalized linear mixed models were then used to evaluate change across all three time points for each measure. Bayesian inference was used to provide the posterior probability of longitudinal effects. RESULTS Nonparametric tests found improvements in seven measures, and longitudinal models supported improvements in 10 measures, with some nonlinear effects. CONCLUSIONS The home-based, remotely supervised intervention improved quantitative measurements of pain in older adults with knee osteoarthritis. This study contributes to the growing body of literature supporting home-based noninvasive stimulation interventions.
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Affiliation(s)
- Robert Suchting
- Faillace Department of Psychiatry and Behavioral Sciences, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Shweta Kapoor
- Faillace Department of Psychiatry and Behavioral Sciences, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Kenneth B Mathis
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Hyochol Ahn
- Department of Research, Cizik School of Nursing, University of Texas Health Science Center at Houston, Houston, Texas, USA
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97
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N-Terminal Pro-B-Type Natriuretic Peptide and Clinical Outcomes. JACC-HEART FAILURE 2020; 8:931-939. [DOI: 10.1016/j.jchf.2020.08.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 02/06/2023]
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98
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Rao A, Scher HI, De Porre P, Yu MK, Londhe A, Qi K, Morris MJ, Ryan C. Impact of clinical versus radiographic progression on clinical outcomes in metastatic castration-resistant prostate cancer. ESMO Open 2020; 5:e000943. [PMID: 33184097 PMCID: PMC7662417 DOI: 10.1136/esmoopen-2020-000943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/04/2020] [Accepted: 09/30/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Unequivocal clinical progression (UCP)-a worsening of clinical status with or without radiographic progression (RAD)-represents a distinct mode of disease progression in metastatic prostate cancer. We evaluated the prevalence, risk factors and the impact of UCP on survival outcomes. METHODS A post-hoc analysis of the COU-AA-302, a randomised phase 3 study of abiraterone plus prednisone (AAP) versus prednisone was performed. Baseline characteristics were summarised. Cox proportional-hazards model and Kaplan-Meier method were used for survival and time to event analyses, respectively. Iterative multiple imputation method was used for correlation between clinicoradiographic progression-free survival (crPFS) and overall survival (OS). RESULTS Of 736 patients with disease progression, 280 (38%) had UCP-only and 124 (17%) had UCP plus RAD. Prognostic index model high-risk group was associated with increased likelihood of UCP (p<0.0001). Median OS was 25.7 months in UCP-only and 33.0 months for RAD-only (HR 1.39; 95% CI 1.16 to 1.66; p=0.0003). UCP adversely impacted OS in both treatment groups. Lowest OS was seen in patients with prostate specific antigen (PSA)-non-response plus UCP-only progression (median OS 22.6 months (95% CI 20.7 to 24.4)). Including UCP events lowered estimates of treatment benefit-median crPFS was 13.3 months (95% CI 11.1 to 13.8) versus median rPFS of 16.5 months (95% CI 13.8 to 16.8) in AAP group. Finally, crPFS showed high correlation with OS (r=0.67; 95% CI 0.63 to 0.71). CONCLUSIONS UCP is a common and clinically relevant phenomenon in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with AAP or prednisone. UCP is prognostic and associated with inferior OS and post-progression survival. A combination of PSA-non-response and UCP identifies patients with poorest survival. When included in PFS analysis, UCP diminishes estimates of treatment benefit. Continued study of UCP in mCRPC is warranted.
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Affiliation(s)
- Arpit Rao
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Howard I Scher
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, United States
| | - Peter De Porre
- Oncology Development, Janssen Research & Development, Beerse, Belgium
| | - Margaret K Yu
- Janssen Research & Development, Los Angeles, California, USA
| | - Anil Londhe
- Oncology Development, Janssen Research & Development, Titusville, New Jersey, USA
| | - Keqin Qi
- Oncology Development, Janssen Research & Development, Titusville, New Jersey, USA
| | - Michael J Morris
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, United States
| | - Charles Ryan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
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99
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Jennings AN, Soder HE, Wardle MC, Schmitz JM, Vujanovic AA. Objective analysis of language use in cognitive-behavioral therapy: associations with symptom change in adults with co-occurring substance use disorders and posttraumatic stress. Cogn Behav Ther 2020; 50:89-103. [PMID: 33021143 DOI: 10.1080/16506073.2020.1819865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Substance use disorders (SUD) commonly co-occur with posttraumatic stress disorder (PTSD) symptoms, and the comorbidity is prevalent and difficult-to-treat. Few studies have objectively analyzed language use in psychotherapy as a predictor of treatment outcomes. We conducted a secondary analysis of patient language use during cognitive-behavioral therapy (CBT) in a randomized clinical trial, comparing a novel, integrated CBT for PTSD/SUD with standard CBT for SUD. Participants included 37 treatment-seeking, predominantly African-American adults with SUD and at least four symptoms of PTSD. We analyzed transcripts of a single, matched session across both treatment conditions, using the Linguistic Inquiry and Word Count (LIWC) program. The program measures language use across multiple categories. Compared to standard CBT for SUD, patients in the novel, integrated CBT for PTSD/SUD used more negative emotion words, partially consistent with our hypothesis, but less positive emotion words. Further, exploratory analyses indicated an association between usage of cognitive processing words and clinician-observed reduction in PTSD symptoms, regardless of treatment condition. Our results suggest that language use during therapy may provide a window into mechanisms active in therapy.
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Affiliation(s)
- Anthony N Jennings
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center , Houston, TX, USA
| | - Heather E Soder
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center , Houston, TX, USA
| | - Margaret C Wardle
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center , Houston, TX, USA.,Department of Psychology, University of Illinois at Chicago , Chicago, IL, USA
| | - Joy M Schmitz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center , Houston, TX, USA
| | - Anka A Vujanovic
- Department of Psychology, University of Houston , Houston, TX, USA
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100
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Schünemann HJ, Ventresca M, Crowther M, Briel M, Zhou Q, Noble S, Macbeth F, Griffiths G, Garcia D, Lyman GH, Di Nisio M, Iorio A, Mbuagbaw L, Neumann I, van Es N, Brouwers M, Guyatt G, Streiff MB, Marcucci M, Baldeh T, Florez ID, Alma OG, Solh Z, Bossuyt PM, Kahale LA, Ageno W, Bozas G, Büller HR, Lebeau B, Lecumberri R, Loprinzi C, McBane R, Sideras K, Maraveyas A, Pelzer U, Perry J, Klerk C, Agnelli G, Akl EA. Evaluating prophylactic heparin in ambulatory patients with solid tumours: a systematic review and individual participant data meta-analysis. Lancet Haematol 2020; 7:e746-e755. [PMID: 32976752 DOI: 10.1016/s2352-3026(20)30293-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Study-level meta-analyses provide high-certainty evidence that heparin reduces the risk of symptomatic venous thromboembolism for patients with cancer; however, whether the benefits and harms associated with heparin differ by cancer type is unclear. This individual participant data meta-analysis of randomised controlled trials examines the effect of heparin on survival, venous thromboembolism, and bleeding in patients with cancer in general and by type. METHODS In this systematic review and meta-analysis we searched MEDLINE, Embase, and The Cochrane Library for randomised controlled trials comparing parenteral anticoagulants with placebo or standard care in ambulatory patients with solid tumours and no indication for anticoagulation published from the inception of each database to January 14, 2017, and updated it on May 14, 2020, without language restrictions. We calculated the effect of parenteral anticoagulant administration on all-cause mortality, venous thromboembolism occurrence, and bleeding related outcomes through multivariable hierarchical models with patient-level variables as fixed effects and a categorical trial variable as a random effect, adjusting for age, cancer type, and metastatic status. Interaction terms were tested to investigate effects in predefined subgroups. This study is registered with PROSPERO, CRD42013003526. FINDINGS We obtained individual participant data from 14 of 20 eligible randomised controlled trials (8278 [79%] of 10 431 participants; 4139 included in the low-molecular-weight heparin group and 4139 in the control group). Meta-analysis showed an adjusted relative risk (RR) of mortality at 1 year of 0·99 (95% CI 0·93-1·06) and a hazard ratio of 1·01 (95% CI 0·96-1·07). The number of patients with venous thromboembolic events was 158 (4·0%) of 3958 with available data in the low-molecular-weight heparin group compared with 279 (7·1%) of 3957 in the control group. Major bleeding events occurred in 71 (1·7%) of 4139 patients in the control population and 88 (2·1%) in the low-molecular-weight heparin group, and minor bleeding events in 478 (12·1%) of 3945 patients with available data in the control group and 652 (16·6%) of 3937 patients in the low-molecular-weight heparin group. The adjusted RR was 0·58 (95% CI 0·47-0·71) for venous thromboembolism, 1·27 (0·92-1·74) for major bleeding, and 1·34 (1·19-1·51) for minor bleeding. Prespecified subgroup analysis of venous thromboembolism occurrence by cancer type identified the most certain benefit from heparin treatment in patients with lung cancer (RR 0·59 [95% CI 0·42-0·81]), which dominated the overall reduction in venous thromboembolism. Certainty of the evidence for the outcomes ranged from moderate to high. INTERPRETATION Low-molecular-weight heparin reduces risk of venous thromboembolism without increasing risk of major bleeding compared with placebo or standard care in patients with solid tumours, but it does not improve survival. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Holger J Schünemann
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Matthew Ventresca
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthias Briel
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Qi Zhou
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, Wales, UK
| | - Fergus Macbeth
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, Wales, UK
| | - Gareth Griffiths
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, Wales, UK; Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - David Garcia
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; University of Washington School of Medicine, Seattle, WA, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G D'Annunzio, Chieti-Pescara, Italy; Department of Vascular Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Alfonso Iorio
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Division of Haematology, Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Haematology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Ignacio Neumann
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nick van Es
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Vascular Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Melissa Brouwers
- Faculty of Medicine, School of Epidemiology and Public Heath, University of Ottawa, Ottawa, ON, Canada
| | - Gordon Guyatt
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maura Marcucci
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tejan Baldeh
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ivan D Florez
- Michael G DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Paediatrics, Universidad de Antioquia, Medellin, Colombia
| | | | - Ziad Solh
- Transfusion Medicine Section, Department of Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Lara A Kahale
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - George Bozas
- Academic Department of Medical Oncology, Castle Hill Hospital, Cottingham, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Bernard Lebeau
- Service de Pneumologie, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Ramon Lecumberri
- Haematology Service, University Clinic of Navarra, Pamplona, Spain
| | - Charles Loprinzi
- Divisions of Cardiology and Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert McBane
- Divisions of Vascular Medicine and Hematology, Mayo Clinic, Rochester, MN, USA
| | - Kostandinos Sideras
- Divisions of Medical Oncology and Hematology, Mayo Clinic, Rochester, MN, USA
| | - Anthony Maraveyas
- Division of Cancer, Hull York Medical School, University of Hull, Hull, UK
| | - Uwe Pelzer
- Division of Haematology, Oncology and Tumour Immunology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität - Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - James Perry
- Ontario Clinical Oncology Group and Department of Oncology, McMaster University, Hamilton, ON, Canada; Division of Neurology, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Clara Klerk
- Department of Internal Medicine, Dijklanderziekenhuis, Hoorn, Netherlands
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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