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Popovic MM, Schlenker MB, Thiruchelvam D, Redelmeier DA. Serious Adverse Events of Oral and Topical Carbonic Anhydrase Inhibitors. JAMA Ophthalmol 2022; 140:235-242. [PMID: 35084437 PMCID: PMC8796060 DOI: 10.1001/jamaophthalmol.2021.5977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Some ophthalmologists may be reluctant to prescribe oral carbonic anhydrase inhibitors, given the potential for life-threatening systemic adverse reactions. OBJECTIVE To conduct a population-based analysis of the safety of oral or topical carbonic anhydrase inhibitors in clinical care. DESIGN, SETTING, AND PARTICIPANTS This matched longitudinal cohort study took place in Ontario, Canada. Consecutive patients older than 65 years who were prescribed an oral or topical carbonic anhydrase inhibitor in Ontario, Canada, between January 1, 1995, and January 1, 2020, were identified. Patients were matched 1-to-1 based on age, sex, and diabetes status. Time zero was defined as the date of the first identified prescription for the medication, and the primary analysis focused on the first 120 days of follow-up. MAIN OUTCOMES AND MEASURES The primary end point was a severe complicated adverse event of either Stevens-Johnson syndrome, toxic epidermal necrolysis, or aplastic anemia. RESULTS Overall, 128 942 matched patients initiated an oral or topical carbonic anhydrase inhibitor during the 25-year study period. The mean (SD) age was 75 (6.6) years, 71 958 (55.8%) were women, and 25 058 (19.4%) had a diagnosis of diabetes. The oral and topical carbonic anhydrase inhibitor groups had similar baseline demographics. Patients prescribed an oral carbonic anhydrase inhibitor had an absolute risk of a severe complicated adverse event of 2.90 per 1000 patients, whereas patients prescribed a topical carbonic anhydrase inhibitor had an absolute risk of 2.08 per 1000 patients. This difference was equivalent to a risk ratio of 1.40, with a number needed to harm of 1 in 1220 patients (95% CI, 1.12-1.74; P = .003). This generally low risk was replicated in multivariable regression controlling for confounding factors. Additional risk factors for a severe complicated adverse event included patients with more comorbidities and those with more frequent clinic contacts. CONCLUSIONS AND RELEVANCE The risk of a serious adverse reaction following prescription of an oral or topical carbonic anhydrase inhibitor was low and similar between agents. Given the low risk of severe adverse reactions, this population-level analysis supports reconsidering the reluctance toward prescribing an oral carbonic anhydrase inhibitor.
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Affiliation(s)
- Marko M. Popovic
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Matthew B. Schlenker
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada,Kensington Vision and Research Centre, Toronto, Ontario, Canada,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada,Institute for Clinical Evaluative Sciences in Ontario, Toronto, Ontario, Canada
| | - Donald A. Redelmeier
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada,Institute for Clinical Evaluative Sciences in Ontario, Toronto, Ontario, Canada,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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2
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Dibato JE, Montvida O, Zaccardi F, Sargeant JA, Davies MJ, Khunti K, Paul SK. Association of Cardiometabolic Multimorbidity and Depression With Cardiovascular Events in Early-Onset Adult Type 2 Diabetes: A Multiethnic Study in the U.S. Diabetes Care 2021; 44:231-239. [PMID: 33177170 DOI: 10.2337/dc20-2045] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/12/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the temporal patterns of cardiometabolic multimorbidity (CM) and depression in White Caucasians (WCs) and African Americans (AAs) with early-onset type 2 diabetes and their impact on long-term atherosclerotic cardiovascular disease (ASCVD). RESEARCH DESIGN AND METHODS From U.S. electronic medical records, 101,104 AA and 505,336 WC subjects with type 2 diabetes diagnosed between 2000 and 2017 were identified (mean follow-up 5.3 years). Among those without ASCVD at diagnosis, risk of ASCVD and three-point major adverse cardiovascular events (MACE-3) (heart failure, myocardial infarction, or stroke) was evaluated between ethnicities by age-groups. RESULTS The proportion of patients diagnosed at <50 years of age increased during 2012-2017 (AA 34-38%, WC 26-29%). Depression prevalence increased during 2000-2017 (AA 15-23%, WC 20-34%), with an increasing trend for CM at diagnosis in both groups. Compared with WC, the adjusted MACE-3 risk was significantly higher in AA across all age-groups, more pronounced in the 18-39-year age-group (hazard ratio 95% CI 1.42, 1.88), and in patients with and without depression. AAs had a 17% (1.05, 1.31) significantly higher adjusted ASCVD risk in the 18-39-year age-group only. Depression was independently associated with ASCVD and MACE-3 risk in both ethnic groups across all age-groups. Other comorbidities were independently associated with ASCVD and MACE-3 risk only among WCs. CONCLUSIONS AAs have higher cardiovascular risk compared with WCs, particularly in early-onset type 2 diabetes. CM and depression at diabetes diagnosis have been increasing over the past two decades in both ethnic groups. Strategies for screening and optimal management of CM and depression, particularly in early-onset type 2 diabetes, may result in a lower cardiovascular risk.
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Affiliation(s)
- John Epoh Dibato
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Victoria, Australia
| | - Olga Montvida
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Victoria, Australia
| | - Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
| | - Jack Alistair Sargeant
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K.,Leicester NIHR Biomedical Research Centre, Leicester, U.K
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K.,Leicester NIHR Biomedical Research Centre, Leicester, U.K
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K.,Leicester NIHR Biomedical Research Centre, Leicester, U.K
| | - Sanjoy K Paul
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Victoria, Australia
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Fukasawa T, Takahashi H, Kameyama N, Fukuda R, Furuhata S, Tanemura N, Amagai M, Urushihara H. Development of an electronic medical record-based algorithm to identify patients with Stevens-Johnson syndrome and toxic epidermal necrolysis in Japan. PLoS One 2019; 14:e0221130. [PMID: 31408480 PMCID: PMC6692049 DOI: 10.1371/journal.pone.0221130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/30/2019] [Indexed: 01/09/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), severe drug reactions, are often misdiagnosed due to their rarity and lack of information on differential diagnosis. The objective of the study was to develop an electronic medical record (EMR)-based algorithm to identify patients with SJS/TEN for future application in database studies. From the EMRs of a university hospital, two dermatologists identified all 13 patients with SJS/TEN seen at the Department of Dermatology as the case group. Another 1472 patients who visited the Department of Dermatology were identified using the ICD-10 codes for diseases requiring differentiation from SJS/TEN. One hundred of these patients were then randomly sampled as controls. Based on clinical guidelines for SJS/TEN and the experience of the dermatologists, we tested 128 algorithms based on the use of ICD-10 codes, clinical courses for SJS/TEN, medical encounters for mucocutaneous lesions from SJS/TEN, and items to exclude paraneoplastic pemphigus. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic odds ratio (DOR) of each algorithm were calculated, and the optimal algorithm was defined as that with high PPV and maximal sensitivity and specificity. One algorithm, consisting of a combination of clinical course for SJS/TEN, medical encounters for mucocutaneous lesions from SJS/TEN, and items to exclude paraneoplastic pemphigus, but not ICD-10 codes, showed a sensitivity of 76.9%, specificity of 99.0%, PPV of 40.5%, NPV of 99.8%, and DOR of 330.00. We developed a potentially optimized algorithm for identifying SJS/TEN based on clinical practice records. The almost perfect specificity of this algorithm will prevent bias in estimating relative risks of SJS/TEN in database studies. Considering the small sample size, this algorithm should be further tested in different settings.
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Affiliation(s)
- Toshiki Fukasawa
- Division of Drug Development and Regulatory Science, Graduate School of Pharmaceutical Sciences, Keio University, Shibakoen, Minato-ku, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Norin Kameyama
- Division of Drug Development and Regulatory Science, Graduate School of Pharmaceutical Sciences, Keio University, Shibakoen, Minato-ku, Tokyo, Japan
| | - Risa Fukuda
- Department of Dermatology, Keio University School of Medicine, Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Shihori Furuhata
- Division of Drug Development and Regulatory Science, Graduate School of Pharmaceutical Sciences, Keio University, Shibakoen, Minato-ku, Tokyo, Japan
| | - Nanae Tanemura
- Division of Drug Development and Regulatory Science, Graduate School of Pharmaceutical Sciences, Keio University, Shibakoen, Minato-ku, Tokyo, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Hisashi Urushihara
- Division of Drug Development and Regulatory Science, Graduate School of Pharmaceutical Sciences, Keio University, Shibakoen, Minato-ku, Tokyo, Japan
- * E-mail:
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Shortreed SM, Cook AJ, Coley RY, Bobb JF, Nelson JC. Challenges and Opportunities for Using Big Health Care Data to Advance Medical Science and Public Health. Am J Epidemiol 2019; 188:851-861. [PMID: 30877288 DOI: 10.1093/aje/kwy292] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
Methodological advancements in epidemiology, biostatistics, and data science have strengthened the research world's ability to use data captured from electronic health records (EHRs) to address pressing medical questions, but gaps remain. We describe methods investments that are needed to curate EHR data toward research quality and to integrate complementary data sources when EHR data alone are insufficient for research goals. We highlight new methods and directions for improving the integrity of medical evidence generated from pragmatic trials, observational studies, and predictive modeling. We also discuss needed methods contributions to further ease data sharing across multisite EHR data networks. Throughout, we identify opportunities for training and for bolstering collaboration among subject matter experts, methodologists, practicing clinicians, and health system leaders to help ensure that methods problems are identified and resulting advances are translated into mainstream research practice more quickly.
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Affiliation(s)
- Susan M Shortreed
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Andrea J Cook
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - R Yates Coley
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Jennifer F Bobb
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Jennifer C Nelson
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
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Basiaga ML, Ross ME, Gerber JS, Ogdie A. Incidence of Pneumocystis jirovecii and Adverse Events Associated With Pneumocystis Prophylaxis in Children Receiving Glucocorticoids. J Pediatric Infect Dis Soc 2018; 7:283-289. [PMID: 28992298 PMCID: PMC6276024 DOI: 10.1093/jpids/pix052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/02/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Antimicrobial prophylaxis is indicated to prevent Pneumocystis jirovecii pneumonia (PJP) in profoundly immunosuppressed children. The incidence of PJP infection in children with chronic glucocorticoid exposure is unknown, and PJP prophylaxis has been associated with adverse events. We hypothesized that PJP infection is rare in children without human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), cancer, or a transplant history who are using chronic glucocorticoids and that those exposed to PJP prophylaxis are more likely to experience a cutaneous hypersensitivity reaction or myelosuppression than unexposed patients. METHODS This study involved a retrospective cohort from the Clinformatics Data Mart Database (OptumInsight, Eden Prairie, MN). We identified patients ≤18 years of age who received at least 2 prescriptions for a systemic glucocorticoid within a 60-day period and excluded patients with a history of PJP infection, an oncologic diagnosis, transplant, or HIV/AIDS. PJP prophylaxis exposure was identified by using national drug codes. Cutaneous hypersensitivity reaction or myelosuppression was identified by using International Classification of Diseases, 9th Revision (ICD-9), codes. We used a discrete time-failure model to examine the association between exposure and outcome. RESULTS We identified 119399 children on glucocorticoids, 10% of whom received PJP prophylaxis. The incidences of PJP were 0.61 and 0.53 per 10000 patient-years in children exposed and those unexposed to PJP prophylaxis, respectively. In a multivariable model, trimethoprim-sulfamethoxazole was associated with cutaneous hypersensitivity reaction (odds ratio, 3.20; 95% confidence interval, 2.62-3.92) and myelosuppression (odds ratio, 1.85; 95% confidence interval, 1.56-2.20). CONCLUSIONS PJP infection was rare in children using glucocorticoids chronically, and PJP prophylaxis-associated cutaneous hypersensitivity reactions and myelosuppression are more common. The use of PJP chemoprophylaxis in children without HIV/AIDS, cancer, or a transplant history who are taking glucocorticoids chronically should be considered carefully.
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Affiliation(s)
- Matthew L Basiaga
- Division of Rheumatology, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine,Correspondence: M. L. Basiaga, DO, MSCE, Seattle Children’s Hospital, 4800 Sand Point Way NE, M.A.7.110, Seattle, WA 98107 ()
| | - Michelle E Ross
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine
| | - Jeffrey S Gerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine,Division of Infectious Diseases, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine
| | - Alexis Ogdie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine,Division of Rheumatology, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine
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6
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Sousa-Pinto B, Araújo L, Freitas A, Correia O, Delgado L. Stevens-Johnson syndrome/toxic epidermal necrolysis and erythema multiforme drug-related hospitalisations in a national administrative database. Clin Transl Allergy 2018; 8:2. [PMID: 29387340 PMCID: PMC5776772 DOI: 10.1186/s13601-017-0188-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/19/2017] [Indexed: 12/17/2022] Open
Abstract
Background Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and erythema multiforme (EM) are immunologically-mediated dermatological disorders commonly triggered by drug exposure and/or other external agents. We aimed to characterise SJS/TEN- and EM-drug-related hospitalisations in a nationwide administrative database, focusing on demographic and clinical characteristics, and in the most frequently implicated drug classes. Methods We analysed all drug-related hospitalisations with associated diagnosis of SJS/TEN or EM in Portuguese hospitals between 2009 and 2014. We compared gender, age, comorbidities, length of stay, and in-hospital mortality and estimated the number of episodes per million packages sold of drug classes. Predictors of in-hospital mortality were investigated in both conditions by logistic regression. Results There were 132 SJS/TEN-related and 122 EM-related hospitalisations. Incidence and in-hospital mortality of SJS/TEN episodes (24.2%) were consistent with previous studies. HIV co-infection was more common among SJS/TEN hospitalisations (9 vs. 2% with EM; P = 0.009). Liver disease, advanced age, and a TEN diagnosis, were significantly associated with higher risk of mortality in patients with SJS/TEN. The highest numbers of SJS/TEN and EM episodes per million drug packages sold were observed for antivirals (8.7 and 1.5, respectively), antineoplastic/immunosuppressive drugs (5.6 and 3.9, respectively) and hypouricaemic drugs (5.0 and 2.4, respectively). Conclusions SJS/TEN in-hospital mortality is high, and its risk factors include advanced age, liver disease, and TEN diagnosis. The drug classes most frequently associated with these conditions include antivirals, hypouricaemic drugs and antineoplastic/immunosuppressive drugs. Administrative databases seem useful in the study of SJS/TEN drug-related hospitalisations, yielding results consistent with previous studies and on a nationwide basis. Electronic supplementary material The online version of this article (10.1186/s13601-017-0188-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bernardo Sousa-Pinto
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,2MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal
| | - Luís Araújo
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,Allergy Unit, CUF Institute, Porto, Portugal
| | - Alberto Freitas
- 2MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal
| | - Osvaldo Correia
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,Epidermis Dermatology Center, CUF Institute, Porto, Portugal
| | - Luís Delgado
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,Allergy Unit, CUF Institute, Porto, Portugal
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7
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Palmaro A, Gauthier M, Conte C, Grosclaude P, Despas F, Lapeyre-Mestre M. Identifying multiple myeloma patients using data from the French health insurance databases: Validation using a cancer registry. Medicine (Baltimore) 2017; 96:e6189. [PMID: 28328805 PMCID: PMC5371442 DOI: 10.1097/md.0000000000006189] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study aimed to assess the performance of several algorithms based on hospital diagnoses and the long-term diseases scheme to identify multiple myeloma patients.Potential multiple myeloma patients in 2010 to 2013 were identified using the presence of hospital records with at least 1 main diagnosis code for multiple myeloma (ICD-10 "C90"). Alternative algorithms also considered related and associated diagnoses, combination with long-term conditions, or at least 2 diagnoses. Incident patients were those with no previous "C90" codes in the past 24 or 12 months. The sensitivity, specificity, and positive and negative predictive values (PPVs and NPVs) were computed, using a French cancer registry for the corresponding area and period as the criterion standard.Long-term conditions data extracted concerned 11,559 patients (21,846 for hospital data). The registry contained 125 cases of multiple myeloma. Sensitivity was 70% when using only main hospital diagnoses (specificity 100%, PPV 79%), 76% when also considering related diagnoses (specificity 100%, PPV 74%), and 90% with associated diagnoses included (100% specificity, 64% PPV).In relation with their good performance, selected algorithms can be used to study the benefit and risk of drugs in treated multiple myeloma patients.
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Affiliation(s)
- Aurore Palmaro
- Medical and Clinical Pharmacology Unit, Toulouse University Hospital
- INSERM 1027, University of Toulouse
- CIC 1436, Toulouse University Hospital
| | | | - Cécile Conte
- Medical and Clinical Pharmacology Unit, Toulouse University Hospital
- INSERM 1027, University of Toulouse
| | - Pascale Grosclaude
- INSERM 1027, University of Toulouse
- Tarn Cancer Registry, Albi
- French Network of Cancer Registries (FRANCIM), France
| | - Fabien Despas
- Medical and Clinical Pharmacology Unit, Toulouse University Hospital
- INSERM 1027, University of Toulouse
- CIC 1436, Toulouse University Hospital
| | - Maryse Lapeyre-Mestre
- Medical and Clinical Pharmacology Unit, Toulouse University Hospital
- INSERM 1027, University of Toulouse
- CIC 1436, Toulouse University Hospital
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Frey N, Bircher A, Bodmer M, Jick SS, Meier CR, Spoendlin J. Validation of Stevens-Johnson syndrome or toxic epidermal necrolysis diagnoses in the Clinical Practice Research Datalink. Pharmacoepidemiol Drug Saf 2016; 26:429-436. [DOI: 10.1002/pds.4124] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 10/05/2016] [Accepted: 10/13/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Noel Frey
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences; University of Basel; Basel Switzerland
- Hospital Pharmacy; University Hospital Basel; Basel Switzerland
| | | | | | - Susan S. Jick
- Boston Collaborative Drug Surveillance Program; Boston University School of Public Health; Lexington MA USA
| | - Christoph R. Meier
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences; University of Basel; Basel Switzerland
- Hospital Pharmacy; University Hospital Basel; Basel Switzerland
- Boston Collaborative Drug Surveillance Program; Boston University School of Public Health; Lexington MA USA
| | - Julia Spoendlin
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences; University of Basel; Basel Switzerland
- Hospital Pharmacy; University Hospital Basel; Basel Switzerland
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9
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Administrative and Survey Data: Potential and Pitfalls. J Invest Dermatol 2016; 136:2122-2124. [DOI: 10.1016/j.jid.2016.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 11/21/2022]
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Ko TM, Tsai CY, Chen SY, Chen KS, Yu KH, Chu CS, Huang CM, Wang CR, Weng CT, Yu CL, Hsieh SC, Tsai JC, Lai WT, Tsai WC, Yin GD, Ou TT, Cheng KH, Yen JH, Liou TL, Lin TH, Chen DY, Hsiao PJ, Weng MY, Chen YM, Chen CH, Liu MF, Yen HW, Lee JJ, Kuo MC, Wu CC, Hung SY, Luo SF, Yang YH, Chuang HP, Chou YC, Liao HT, Wang CW, Huang CL, Chang CS, Lee MTM, Chen P, Wong CS, Chen CH, Wu JY, Chen YT, Shen CY. Use of HLA-B*58:01 genotyping to prevent allopurinol induced severe cutaneous adverse reactions in Taiwan: national prospective cohort study. BMJ 2015; 351:h4848. [PMID: 26399967 PMCID: PMC4579807 DOI: 10.1136/bmj.h4848] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the use of prospective screening for the HLA-B*58:01 allele to identify Taiwanese individuals at risk of severe cutaneous adverse reactions (SCARs) induced by allopurinol treatment. DESIGN National prospective cohort study. SETTING 15 medical centres in different regions of Taiwan, from July 2009 to August 2014. PARTICIPANTS 2926 people who had an indication for allopurinol treatment but had not taken allopurinol previously. Participants were excluded if they had undergone a bone marrow transplant, were not of Han Chinese descent, and had a history of allopurinol induced hypersensitivity. DNA purified from 2910 participants' peripheral blood was used to assess the presence of HLA-B*58:01. MAIN OUTCOME MEASURES Incidence of allopurinol induced SCARs with and without screening. RESULTS Participants who tested positive for HLA-B*58:01 (19.6%, n=571) were advised to avoid allopurinol, and were referred to an alternate drug treatment or advised to continue with their prestudy treatment. Participants who tested negative (80.4%, n=2339) were given allopurinol. Participants were interviewed once a week for two months to monitor symptoms. The historical incidence of allopurinol induced SCARs, estimated by the National Health Insurance research database of Taiwan, was used for comparison. Mild, transient rash without blisters developed in 97 (3%) participants during follow-up. None of the participants was admitted to hospital owing to adverse drug reactions. SCARs did not develop in any of the participants receiving allopurinol who screened negative for HLA-B*58:01. By contrast, seven cases of SCARs were expected, based on the estimated historical incidence of allopurinol induced SCARs nationwide (0.30% per year, 95% confidence interval 0.28% to 0.31%; P=0.0026; two side one sample binomial test). CONCLUSIONS Prospective screening of the HLA-B*58:01 allele, coupled with an alternative drug treatment for carriers, significantly decreased the incidence of allopurinol induced SCARs in Taiwanese medical centres.
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Affiliation(s)
- Tai-Ming Ko
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Chang-Youh Tsai
- Division of Allergy, Immunology, and Rheumatology, Taipei Veterans General Hospital, Taipei Faculty of Medicine, National Yang Ming University, Taipei
| | | | | | | | - Chih-Sheng Chu
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Chung-Ming Huang
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan China Medical University Hospital, Taichung
| | | | - Chia-Tse Weng
- National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Li Yu
- National Taiwan University Hospital, Taipei
| | | | - Jer-Chia Tsai
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Wen-Ter Lai
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Wen-Chan Tsai
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | | | - Tsan-Teng Ou
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Kai-Hung Cheng
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Jeng-Hsien Yen
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Teh-Ling Liou
- Division of Allergy, Immunology, and Rheumatology, Taipei Veterans General Hospital, Taipei
| | - Tsung-Hsien Lin
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Der-Yuan Chen
- Faculty of Medicine, National Yang Ming University, Taipei Department of Medical Education and Research, and Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, National Chung Hsing University, Taichung
| | - Pi-Jung Hsiao
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Meng-Yu Weng
- National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Ming Chen
- Faculty of Medicine, National Yang Ming University, Taipei Department of Medical Education and Research, and Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, National Chung Hsing University, Taichung
| | | | - Ming-Fei Liu
- National Cheng Kung University Hospital, Tainan, Taiwan
| | - Hsueh-Wei Yen
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Jia-Jung Lee
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Chuan Kuo
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung
| | - Chen-Ching Wu
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Shih-Yuan Hung
- Division of Nephrology, E-Da Hospital, Kaohsiung School of Medicine, I-Shou University, Kaohsiung
| | - Shue-Fen Luo
- Chang Gung Memorial Hospital, Taoyuan, Taiwan Chang Gung University, Taoyuan
| | - Ya-Hui Yang
- Department of Occupational Safety and Hygiene, Fooyin University, Kaohsiung Department of Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hui-Ping Chuang
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Yi-Chun Chou
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Hung-Ting Liao
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Chia-Wen Wang
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Chun-Lin Huang
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Chia-Shuo Chang
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Ming-Ta Michael Lee
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan Laboratory for International Alliance on Genomic Research, Core for Genomic Medicine, RIKEN Centre for Integrative Medical Sciences, Yokohama, Kanagawa, Japan
| | - Pei Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Chih-Shung Wong
- Department of Anaesthesiology, Cathay General Hospital, Taipei PharmiGene, Taipei
| | - Chien-Hsiun Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan School of Chinese Medicine, China Medical University, Taichung
| | - Jer-Yuarn Wu
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan School of Chinese Medicine, China Medical University, Taichung
| | - Yuan-Tsong Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Chen-Yang Shen
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan College of Public Health, China Medical University Hospital, Taichung Taiwan Biobank, Academia Sinica, Taipei
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11
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Davis RL, Gallagher MA, Asgari MM, Eide MJ, Margolis DJ, Macy E, Burmester JK, Selvam N, Boscarino JA, Cromwell LF, Feigelson HS, Kuntz JL, Pawloski PA, Penfold RB, Raebel MA, Sridhar G, Wu A, La Grenade LA, Pacanowski MA, Pinheiro SP. Identification of Stevens-Johnson syndrome and toxic epidermal necrolysis in electronic health record databases. Pharmacoepidemiol Drug Saf 2015; 24:684-92. [PMID: 25914229 DOI: 10.1002/pds.3778] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 01/26/2015] [Accepted: 03/08/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) carry a high mortality risk. While identifying clinical and genetic risk factors for these conditions has been hindered by their rarity, large electronic health databases hold promise for identifying large numbers of cases for study, especially with the introduction in 2008 of ICD-9 codes more specific for these conditions. OBJECTIVE The objective of this study is to estimate the validity of ICD-9 codes for ascertaining SJS/TEN in 12 collaborating research units in the USA, covering almost 60 million lives. METHODS From the electronic databases at each site, we ascertained potential cases of SJS/TEN using ICD-9 codes. At five sites, a subset of medical records was abstracted and standardized criteria applied by board-certified dermatologists to adjudicate diagnoses. Multivariate logistic regression was used to identify factors independently associated with validated SJS/TEN cases. RESULTS A total of 56 591 potential cases of SJS/TEN were identified. A subset of 276 charts was selected for adjudication and 39 (of the 276) were confirmed as SJS/TEN. Patients with the ICD-9 codes introduced after 2008 were more likely to be confirmed as cases (OR 3.32; 95%CI 0.82, 13.47) than those identified in earlier years. Likelihood of case status increased with length of hospitalization. Applying the probability of case status to the 56 591 potential cases, we estimated 475-875 to be valid SJS/TEN cases. CONCLUSION Newer ICD-9 codes, along with length of hospitalization, identified patients with a high likelihood of SJS/TEN. This is important for identification of subjects for future pharmacogenomics studies.
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Affiliation(s)
- Robert L Davis
- University of Tennessee Health Sciences Center, Memphis, TN, USA.,Kaiser Permanente Georgia, Atlanta, GA, USA
| | | | | | | | | | - Eric Macy
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | | | | | | | | | | | - Pamala A Pawloski
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | | | | | - Ann Wu
- Harvard Pilgrim Health Care, Boston, MA, USA
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12
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Bascones-Martínez A, García-García V, Meurman JH, Requena-Caballero L. Immune-mediated diseases: what can be found in the oral cavity? Int J Dermatol 2014; 54:258-70. [PMID: 25514833 DOI: 10.1111/ijd.12681] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immune-mediated diseases frequently affect oral mucosa, which may often be the first site of clinical manifestation. In this review, we describe the most important oral lesions related to inflammatory disorders and present their management and novel therapies. The review is based on an open PubMed literature search from 1980 to 2012 with relevant keywords. Pemphigus vulgaris, oral lichen planus, cicatricial pemphigoid, erythema multiforme, Stevens-Johnson syndrome, systemic lupus erythematosus, Sjögren's syndrome, and linear IgA dermatosis are the immune-mediated diseases with oral manifestations discussed. Etiology is unknown in most of these diseases, but recently some of them have been found to share common genes. Modern treatment of these diseases is based on drugs that interfere along the pathogenic mechanisms instead of the still commonly used palliative measures. However, the immunomodulatory drugs may also cause oral side effects, complicating the clinical picture. Therefore, consulting dental or oral medicine specialists can be necessary in some cases with various immune-mediated diseases.
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Affiliation(s)
- Antonio Bascones-Martínez
- Department of Stomatology III, Faculty of Odontology, Complutense University of Madrid, Madrid, Spain
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13
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Kim SC, Newcomb C, Margolis D, Roy J, Hennessy S. Severe cutaneous reactions requiring hospitalization in allopurinol initiators: a population-based cohort study. Arthritis Care Res (Hoboken) 2013; 65:578-84. [PMID: 22899369 PMCID: PMC3502684 DOI: 10.1002/acr.21817] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 07/27/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Rare but potentially life-threatening cutaneous adverse reactions have been associated with allopurinol, but population-based data on the incidence and mortality of such reactions are scarce. METHODS We conducted a propensity score-matched cohort study to evaluate the incidence rate (IR) and in-hospital mortality of hospitalization for severe cutaneous adverse reactions (SCARs) in allopurinol initiators compared to non-allopurinol users, using data from 5 large Medicaid programs. The primary outcome was identified by the principal discharge diagnosis code 695.1. A Cox proportional hazards model evaluated the relative risk of SCARs associated with the use of allopurinol and determined the relative risk of SCARs associated with allopurinol dose. RESULTS During a followup period of 65,625 person-years for allopurinol initiators, 45 were hospitalized with SCARs. The crude IR was 0.69 (95% confidence interval [95% CI] 0.50-0.92) per 1,000 person-years. All 45 cases occurred within 365 days and 41 (91.1%) occurred within 180 days after initiating treatment with allopurinol. Twelve patients (26.7%) died during the hospitalization. The crude IR in non-allopurinol users was 0.04 (95% CI 0.02-0.08) per 1,000 person-years. The risk of SCARs was increased in allopurinol initiators versus nonusers (hazard ratio [HR] 9.68, 95% CI 4.55-20.57). Among allopurinol initiators, the HR for high-dosage (>300 mg/day) versus low-dosage allopurinol was 1.30 (95% CI 0.31-5.36) after adjusting for age, comorbidities, and recent diuretic use. CONCLUSION Among allopurinol initiators, SCARs were found to be rare but often fatal, and occurred mostly in the first 180 days of treatment. The risk of SCARs was 10 times as high in allopurinol initiators as compared to allopurinol nonusers.
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Affiliation(s)
- Seoyoung C Kim
- Brigham and Women's Hospital, Boston, Massachusetts, USA.
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14
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Carnahan RM, Moores KG. Mini-Sentinel's systematic reviews of validated methods for identifying health outcomes using administrative and claims data: methods and lessons learned. Pharmacoepidemiol Drug Saf 2012; 21 Suppl 1:82-9. [PMID: 22262596 DOI: 10.1002/pds.2321] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PURPOSE To overview the methods used in the Mini-Sentinel systematic reviews of validation studies of algorithms to identify health outcomes in administrative and claims data and to describe lessons learned in the development of search strategies, including their ability to identify articles from previous systematic reviews which used different search strategies. METHODS Literature searches were conducted using PubMed and the citation database of the Iowa Drug Information Service. Embase was searched for some outcomes. The searches were based on a strategy developed by the Observational Medical Outcomes Partnership (OMOP) researchers. All citations were reviewed by two investigators. Exclusion criteria were applied at abstract and full-text review stages to ultimately identify algorithm validation studies that used data sources from the USA or Canada, as the results of these studies were considered most likely to generalize to Mini-Sentinel data. Nonvalidated algorithms were reviewed if fewer than five algorithm validation studies were identified. RESULTS The results of this project are described in the separate articles and reports written on algorithms to identify each outcome of interest. CONCLUSIONS The Mini-Sentinel systematic reviews of algorithms to identify health outcomes in administrative and claims data are expected to be relatively complete, despite some limitations. Algorithm validation studies are inconsistently indexed in PubMed, creating challenges in conducting systematic reviews of these studies. Google Scholar searches, which can perform text word searches of electronically available articles, are suggested as a strategy to identify studies that are not captured through searches of standard citation databases.
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Affiliation(s)
- Ryan M Carnahan
- Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, IA 52242, USA.
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15
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Platt R, Carnahan RM, Brown JS, Chrischilles E, Curtis LH, Hennessy S, Nelson JC, Racoosin JA, Robb M, Schneeweiss S, Toh S, Weiner MG. The U.S. Food and Drug Administration's Mini-Sentinel program: status and direction. Pharmacoepidemiol Drug Saf 2012; 21 Suppl 1:1-8. [PMID: 22262586 DOI: 10.1002/pds.2343] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Mini-Sentinel is a pilot program that is developing methods, tools, resources, policies, and procedures to facilitate the use of routinely collected electronic healthcare data to perform active surveillance of the safety of marketed medical products, including drugs, biologics, and medical devices. The U.S. Food and Drug Administration (FDA) initiated the program in 2009 as part of its Sentinel Initiative, in response to a Congressional mandate in the FDA Amendments Act of 2007. After two years, Mini-Sentinel includes 31 academic and private organizations. It has developed policies, procedures, and technical specifications for developing and operating a secure distributed data system comprised of separate data sets that conform to a common data model covering enrollment, demographics, encounters, diagnoses, procedures, and ambulatory dispensing of prescription drugs. The distributed data sets currently include administrative and claims data from 2000 to 2011 for over 300 million person-years, 2.4 billion encounters, 38 million inpatient hospitalizations, and 2.9 billion dispensings. Selected laboratory results and vital signs data recorded after 2005 are also available. There is an active data quality assessment and characterization program, and eligibility for medical care and pharmacy benefits is known. Systematic reviews of the literature have assessed the ability of administrative data to identify health outcomes of interest, and procedures have been developed and tested to obtain, abstract, and adjudicate full-text medical records to validate coded diagnoses. Mini-Sentinel has also created a taxonomy of study designs and analytical approaches for many commonly occurring situations, and it is developing new statistical and epidemiologic methods to address certain gaps in analytic capabilities. Assessments are performed by distributing computer programs that are executed locally by each data partner. The system is in active use by FDA, with the majority of assessments performed using customizable, reusable queries (programs). Prospective and retrospective assessments that use customized protocols are conducted as well. To date, several hundred unique programs have been distributed and executed. Current activities include active surveillance of several drugs and vaccines, expansion of the population, enhancement of the common data model to include additional types of data from electronic health records and registries, development of new methodologic capabilities, and assessment of methods to identify and validate additional health outcomes of interest.
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Affiliation(s)
- Richard Platt
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
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Carnahan RM. Mini-Sentinel's systematic reviews of validated methods for identifying health outcomes using administrative data: summary of findings and suggestions for future research. Pharmacoepidemiol Drug Saf 2012; 21 Suppl 1:90-9. [DOI: 10.1002/pds.2318] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Ryan M. Carnahan
- Department of Epidemiology; The University of Iowa College of Public Health; Iowa City IA USA
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