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Stempel DA, Szefler SJ. Is the assessment of asthma treatment efficacy sufficiently comprehensive? J Allergy Clin Immunol 2024; 153:629-636. [PMID: 38135011 DOI: 10.1016/j.jaci.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/21/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
The goal of asthma guideline therapy is to achieve disease control, by minimizing impairment and decreasing the risk of exacerbations and adverse effects of the disease and its treatment. The primary objective of most clinical trials of biologics for severe asthma is a reduction in exacerbation rate. Recently, studies with patients at the lower guideline steps have also selected exacerbation reduction as a primary objective. These trials in patients with milder disease frequently demonstrate statistically significantly fewer exacerbations, but their power calculations reflect larger sample size and smaller effect size. Exacerbations have a precise consensus definition, although a minimal clinically important difference has not been established. Reduction of exacerbations in severe asthma is commonly 10-fold greater than in mild disease. Further, reduction in exacerbations is not always associated with reduced impairment. If superior control is the objective, both domains should demonstrate consistent and parallel improvement. The disconnect may reflect the need for alternative tools for measurement of impairment or, possibly, different therapeutic mechanisms of action. Determining response to biologics or discussion of disease remission requires assessing symptoms that may occur daily rather than focusing on exacerbations that occur once or twice a year for patients at the highest steps of care according to the guidelines.
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Affiliation(s)
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
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2
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Boentert M, Berger KI, Díaz-Manera J, Dimachkie MM, Hamed A, Riou França L, Thibault N, Shukla P, Ishak J, Caro JJ. Applying the win ratio method in clinical trials of orphan drugs: an analysis of data from the COMET trial of avalglucosidase alfa in patients with late-onset Pompe disease. Orphanet J Rare Dis 2024; 19:14. [PMID: 38216959 PMCID: PMC10785533 DOI: 10.1186/s13023-023-02974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 11/18/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Clinical trials for rare diseases often include multiple endpoints that capture the effects of treatment on different disease domains. In many rare diseases, the primary endpoint is not standardized across trials. The win ratio approach was designed to analyze multiple endpoints of interest in clinical trials and has mostly been applied in cardiovascular trials. Here, we applied the win ratio approach to data from COMET, a phase 3 trial in late-onset Pompe disease, to illustrate how this approach can be used to analyze multiple endpoints in the orphan drug context. METHODS All possible participant pairings from both arms of COMET were compared sequentially on changes at week 49 in upright forced vital capacity (FVC) % predicted and six-minute walk test (6MWT). Each participant's response for the two endpoints was first classified as a meaningful improvement, no meaningful change, or a meaningful decline using thresholds based on published minimal clinically important differences (FVC ± 4% predicted, 6MWT ± 39 m). Each comparison assessed whether the outcome with avalglucosidase alfa (AVA) was better than (win), worse than (loss), or equivalent to (tie) the outcome with alglucosidase alfa (ALG). If tied on FVC, 6MWT was compared. In this approach, the treatment effect is the ratio of wins to losses ("win ratio"), with ties excluded. RESULTS In the 2499 possible pairings (51 receiving AVA × 49 receiving ALG), the win ratio was 2.37 (95% confidence interval [CI], 1.30-4.29, p = 0.005) when FVC was compared before 6MWT. When the order was reversed, the win ratio was 2.02 (95% CI, 1.13-3.62, p = 0.018). CONCLUSION The win ratio approach can be used in clinical trials of rare diseases to provide meaningful insight on treatment benefits from multiple endpoints and across disease domains.
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Affiliation(s)
- Matthias Boentert
- Department of Neurology and Institute of Translational Neurology, Münster University Hospital, Münster, Germany
| | - Kenneth I Berger
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jordi Díaz-Manera
- John Walton Muscular Dystrophy Research Centre, Newcastle University Centre for Life, Newcastle Upon Tyne, UK
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | | | | | - J Jaime Caro
- Evidera, Boston, MA, USA.
- McGill University, Montreal, QC, Canada.
- London School of Economics, London, UK.
- Evidera, 500 Totten Pond Rd, Waltham, MA, 02451, USA.
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3
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Miot HA. Analysis of data with dependent measures in clinical and experimental studies. J Vasc Bras 2023; 22:e20220150. [PMID: 37333755 PMCID: PMC10275643 DOI: 10.1590/1677-5449.202201502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/14/2023] [Indexed: 06/20/2023] Open
Affiliation(s)
- Hélio Amante Miot
- Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP, Faculdade de Medicina de Botucatu - FMB, Departamento de Infectologia, Dermatologia, Diagnóstico por Imagem e Radioterapia, Botucatu, SP, Brasil.
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O'Halloran D, Thomacos N, Casey S, Farnworth L. A secondary analysis to develop a scale for measuring unemployed workers' experiences of Australian employment services. Work 2021; 70:805-813. [PMID: 34719451 DOI: 10.3233/wor-205120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Research consistently shows that Australian employment services are failing those they are intended to serve. Based on findings in other human service areas, a valid and reliable instrument to measure unemployed workers' experiences may provide an opportunity for improvement in this sector. OBJECTIVE To establish a basis for developing a suitable rating scale. METHODS An exploratory factor analysis combined with qualitative cross check for face validity of an existing large survey of Australian unemployed workers. RESULTS Six factors appear to be important elements of service delivery: (F1) useful and competent, (F2) client-centred, (F3) receptive to feedback, (F4) trustworthy, (F5) fair, and (F6) friendlyCONCLUSIONS:While each of these factors have been either described explicitly or referred to implicitly in previous studies, this study is the first to attempt to combine these factors and is a precursor to establishing a valid and reliable rating scale for use by unemployed workers in evaluating their employment service providers. At a time when Australia is exploring new approaches to employment services, such a scale using a robust set of factors may allow for the improvement of employment services and thus be held accountable to a significant stakeholder group whom they aim to serve -unemployed workers.
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Affiliation(s)
- David O'Halloran
- Department of Occupational Therapy, School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, VIC, Australia
| | - Nikos Thomacos
- Department of Occupational Therapy, School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, VIC, Australia
| | - Simone Casey
- Future Social Service Institute, RMIT University, Carlton, VIC, Australia
| | - Louise Farnworth
- Department of Occupational Therapy, School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, VIC, Australia
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Hide M, Suzuki T, Tanaka A, Aoki H. Efficacy of increased dose of rupatadine up to 20 mg on itching in Japanese patients due to chronic spontaneous urticaria, dermatitis, or pruritus: A post hoc analysis of phase III clinical trial. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2019. [DOI: 10.1002/cia2.12072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Michihiro Hide
- Department of Dermatology, Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
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Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:98. [PMID: 30340460 PMCID: PMC6742918 DOI: 10.1186/s10194-018-0928-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PRESTO study of non-invasive vagus nerve stimulation (nVNS; gammaCore®) featured key primary and secondary end points recommended by the International Headache Society to provide Class I evidence that for patients with an episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. Here, we examined additional data from PRESTO to provide further insights into the practical utility of nVNS by evaluating its ability to consistently deliver clinically meaningful improvements in pain intensity while reducing the need for rescue medication. METHODS Patients recorded pain intensity for treated migraine attacks on a 4-point scale. Data were examined to compare nVNS and sham with regard to the percentage of patients who benefited by at least 1 point in pain intensity. We also assessed the percentage of attacks that required rescue medication and pain-free rates stratified by pain intensity at treatment initiation. RESULTS A significantly higher percentage of patients who used acute nVNS treatment (n = 120) vs sham (n = 123) reported a ≥ 1-point decrease in pain intensity at 30 min (nVNS, 32.2%; sham, 18.5%; P = 0.020), 60 min (nVNS, 38.8%; sham, 24.0%; P = 0.017), and 120 min (nVNS, 46.8%; sham, 26.2%; P = 0.002) after the first attack. Similar significant results were seen when assessing the benefit in all attacks. The proportion of patients who did not require rescue medication was significantly higher with nVNS than with sham for the first attack (nVNS, 59.3%; sham, 41.9%; P = 0.013) and all attacks (nVNS, 52.3%; sham, 37.3%; P = 0.008). When initial pain intensity was mild, the percentage of patients with no pain after treatment was significantly higher with nVNS than with sham at 60 min (all attacks: nVNS, 37.0%; sham, 21.2%; P = 0.025) and 120 min (first attack: nVNS, 50.0%; sham, 25.0%; P = 0.018; all attacks: nVNS, 46.7%; sham, 30.1%; P = 0.037). CONCLUSIONS This post hoc analysis demonstrated that acute nVNS treatment quickly and consistently reduced pain intensity while decreasing rescue medication use. These clinical benefits provide guidance in the optimal use of nVNS in everyday practice, which can potentially reduce use of acute pharmacologic medications and their associated adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02686034 .
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Affiliation(s)
- Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
- Department of Fondazione IRCCS Istituto Neurologico C. Besta, U.O. Neurologia III – Cefalee e Neuroalgologia, Via Celoria 11, 20133 Milan, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
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Kagan A, Simmons-Mackie N, Victor JC. The Impact of Exposure With No Training: Implications for Future Partner Training Research. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2018; 61:2347-2352. [PMID: 30208393 DOI: 10.1044/2018_jslhr-l-17-0413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 05/18/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE This research note reports on an unexpected negative finding related to behavior change in a controlled trial designed to test whether partner training improves the conversational skills of volunteers. METHOD The clinical trial involving training in "Supported Conversation for Adults with Aphasia" utilized a single-blind, randomized, controlled, pre-post design. Eighty participants making up 40 dyads of a volunteer conversation partner and an adult with aphasia were randomly allocated to either an experimental or control group of 20 dyads each. Descriptive statistics including exact 95% confidence intervals were calculated for the percentage of control group participants who got worse after exposure to individuals with aphasia. RESULTS Positive outcomes of training in Supported Conversation for Adults with Aphasia for both the trained volunteers and their partners with aphasia were reported by Kagan, Black, Felson Duchan, Simmons-Mackie, and Square in 2001. However, post hoc data analysis revealed that almost one third of untrained control participants had a negative outcome rather than the anticipated neutral or slightly positive outcome. CONCLUSIONS If the results of this small study are in any way representative of what happens in real life, communication partner training in aphasia becomes even more important than indicated from the positive results of training studies. That is, it is possible that mere exposure to a communication disability such as aphasia could have negative impacts on communication and social interaction. This may be akin to what is known as a "nocebo" effect-something for partner training studies in aphasia to take into account.
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Murphy BR, Doohan FM, Hodkinson TR. From Concept to Commerce: Developing a Successful Fungal Endophyte Inoculant for Agricultural Crops. J Fungi (Basel) 2018; 4:E24. [PMID: 29439471 PMCID: PMC5872327 DOI: 10.3390/jof4010024] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/02/2018] [Accepted: 02/09/2018] [Indexed: 12/17/2022] Open
Abstract
The development of endophyte inoculants for agricultural crops has been bedevilled by the twin problems of a lack of reliability and consistency, with a consequent lack of belief among end users in the efficacy of such treatments. We have developed a successful research pipeline for the production of a reliable, consistent and environmentally targeted fungal endophyte seed-delivered inoculant for barley cultivars. Our approach was developed de novo from an initial concept to source candidate endophyte inoculants from a wild relative of barley, Hordeum murinum (wall barley). A careful screening and selection procedure and extensive controlled environment testing of fungal endophyte strains, followed by multi-year field trials has resulted in the validation of an endophyte consortium suitable for barley crops grown on relatively dry sites. Our approach can be adapted for any crop or environment, provided that the set of first principles we have developed is followed. Here, we report how we developed the successful pipeline for the production of an economically viable fungal endophyte inoculant for barley cultivars.
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Affiliation(s)
- Brian R Murphy
- School of Natural Sciences & Trinity Centre for Biodiversity Research, Trinity College Dublin, The University of Dublin, College Green, Dublin 2, Ireland.
| | - Fiona M Doohan
- UCD School of Biology & Environmental Science and UCD Earth Institute, University College Dublin, Dublin 4, Ireland.
| | - Trevor R Hodkinson
- School of Natural Sciences & Trinity Centre for Biodiversity Research, Trinity College Dublin, The University of Dublin, College Green, Dublin 2, Ireland.
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Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ 2017; 359:j4366. [PMID: 29018008 PMCID: PMC6284261 DOI: 10.1136/bmj.j4366] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective To examine the effect of surgeon sex on postoperative outcomes of patients undergoing common surgical procedures.Design Population based, retrospective, matched cohort study from 2007 to 2015.Setting Population based cohort of all patients treated in Ontario, Canada.Participants Patients undergoing one of 25 surgical procedures performed by a female surgeon were matched by patient age, patient sex, comorbidity, surgeon volume, surgeon age, and hospital to patients undergoing the same operation by a male surgeon.Interventions Sex of treating surgeon.Main outcome measure The primary outcome was a composite of death, readmission, and complications. We compared outcomes between groups using generalised estimating equations.Results 104 630 patients were treated by 3314 surgeons, 774 female and 2540 male. Before matching, patients treated by female doctors were more likely to be female and younger but had similar comorbidity, income, rurality, and year of surgery. After matching, the groups were comparable. Fewer patients treated by female surgeons died, were readmitted to hospital, or had complications within 30 days (5810 of 52 315, 11.1%, 95% confidence interval 10.9% to 11.4%) than those treated by male surgeons (6046 of 52 315, 11.6%, 11.3% to 11.8%; adjusted odds ratio 0.96, 0.92 to 0.99, P=0.02). Patients treated by female surgeons were less likely to die within 30 days (adjusted odds ratio 0.88; 0.79 to 0.99, P=0.04), but there was no significant difference in readmissions or complications. Stratified analyses by patient, physician, and hospital characteristics did not significant modify the effect of surgeon sex on outcome. A retrospective analysis showed no difference in outcomes by surgeon sex in patients who had emergency surgery, where patients do not usually choose their surgeon.Conclusions After accounting for patient, surgeon, and hospital characteristics, patients treated by female surgeons had a small but statistically significant decrease in 30 day mortality and similar surgical outcomes (length of stay, complications, and readmission), compared with those treated by male surgeons. These findings support the need for further examination of the surgical outcomes and mechanisms related to physicians and the underlying processes and patterns of care to improve mortality, complications, and readmissions for all patients.
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Affiliation(s)
- Christopher Jd Wallis
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto
| | - Bheeshma Ravi
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre
| | - Natalie Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, ON M4N 3M5, Canada
| | - Allan S Detsky
- Institute of Health Policy, Management, and Evaluation, University of Toronto
- Department of Medicine, Mount Sinai Hospital, University Health Network, University of Toronto
| | - Raj Satkunasivam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, ON M4N 3M5, Canada
- Department of Urology and Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
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Mechanick JI, Pessah-Pollack R, Camacho P, Correa R, Figaro MK, Garber JR, Jasim S, Pantalone KM, Trence D, Upala S. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE. Endocr Pract 2017; 23:1006-1021. [PMID: 28786720 DOI: 10.4158/ep171866.gl] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment. ABBREVIATIONS AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.
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CeasIng Cpap At standarD criteriA (CICADA): predicting a successful outcome. Eur J Pediatr 2016; 175:81-7. [PMID: 26231684 DOI: 10.1007/s00431-015-2603-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED This is a retrospective analysis of a multicentre randomised controlled trial (RCT) where we concluded that CeasIng Cpap At standerD criteriA (CICADA) in premature babies (PBs) <30 weeks gestational age (GA) was the significantly better method of ceasing CPAP. To identify factors that may influence the number of attempts to cease CPAP, we reviewed the records of 50 PBs from the RCT who used the CICADA method. PBs were grouped according to number of attempts to cease CPAP (fast group ≤2 attempts and slow group >2 attempts to cease CPAP). There were 26 (fast group) and 24 (slow group) PBs included in the analysis. Results showed significant differences in mean GA (27.8 ± 0.3 vs 26.9 ± 0.3 [weeks ± SE], p = 0.03) and birth weight ([Bwt]; 1080 ± 48.8 vs 899 ± 45.8 [grams ± SE], p = 0.01) between groups. Significantly fewer PBs in the fast group had a patent ductus arteriosus (PDA) compared to the slow group (5/26 (19.2%) vs 13/24 (54.2 %), p = 0.02). Bwt was a significant negative predictor of CPAP duration (r = -0.497, p = 0.03) and CPAP ceasing attempts (r = -0.290, p = 0.04). CONCLUSION PBs with a higher GA and Bwt without a PDA ceased CPAP earlier using the CICADA method. Bwt was better than GA for predicting CPAP duration and attempts to cease CPAP. WHAT IS KNOWN Our previous studies showed that CeasIng Cpap At standarD criteriA (CICADA) significantly reduces CPAP time, oxygen requirements and caffeine use. Some PBs however using the CICADA method required >2 attempts to cease CPAP ('slow CICADA' group). WHAT IS NEW PBs in the 'fast CICADA' group (<3 attempts to cease CPAP) (a) have longer gestational age and higher birth weight, (b) shorter mechanical ventilation and (c) lower incidence of patent ductus arteriosus. Attempts to cease CPAP decreased by 0.5 times per 1 week increase in GA and 0.3 times per 100-g increase in birth weight for PBs <30 weeks gestation.
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Zuckermann A, Eisen H, See Tai S, Li H, Hahn C, Crespo-Leiro MG. Sirolimus conversion after heart transplant: risk factors for acute rejection and predictors of renal function response. Am J Transplant 2014; 14:2048-54. [PMID: 25307036 DOI: 10.1111/ajt.12833] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/25/2023]
Abstract
In a randomized, comparative study of cardiac transplant patients with mild-to-moderate renal insufficiency, conversion from calcineurin inhibitors (CNIs) to sirolimus improved renal function at 1 year versus continuing CNIs, with an attendant risk of biopsy-confirmed acute rejection (BCAR). Post hoc analyses were conducted to identify predictors of BCAR and GFR improvement associated with conversion. Patients with proteinuria >500 mg/day were excluded. Univariate and multivariate regression analyses tested 13 parameters for BCAR and six for GFR improvement. In 57 sirolimus-treated patients, mean daily mycophenolate mofetil (MMF) dose was lower in those with versus without BCAR (1000 vs. 1420 mg; p = 0.014). Receiver operating characteristic analysis identified MMF dose ≤1000 mg/day as the optimal cutoff to predict BCAR. Multivariate analysis confirmed low MMF dose (odds ratio: 9.94; p = 0.007) and non-white race (odds ratio: 15.3; p = 0.06) were independently associated with BCAR. GFR improvement was evaluated in intent-to-treat patients (n = 116). Significant interaction was detected between treatment effect and preexisting diabetes status (univariate p = 0.077; multivariate p = 0.022), indicating greater beneficial effect of sirolimus in those without preexisting diabetes. These findings suggest that sirolimus is more effective in improving GFR in patients without preexisting diabetes, and adequate MMF doses are needed for sirolimus conversion.
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Abstract
In July 2013, the US Food and Drug Administration approved levomilnacipran extended release (ER; Fetzima), a serotonin-norepinephrine reuptake inhibitor, for the treatment of adults with major depressive disorder. Levomilnacipran is an active enantiomer of the racemic drug milnacipran that is currently approved in the United States for the treatment of fibromyalgia. This article provides an overview of the mechanism of action, pharmacokinetic properties, clinical efficacy, safety, and tolerability of levomilnacipran ER. Relevant information was identified through a search of databases using the key word levomilnacipran. Additional information was obtained from fda.gov, by a review of the reference lists of identified articles, and from posters and abstracts from scientific meetings. Levomilnacipran ER, dosed once daily, is generally well tolerated and has demonstrated favorable effects compared to placebo in clinical trials of patients with major depressive disorder. The increased potency for norepinephrine reuptake inhibition is a characteristic that may represent a novel contribution for levomilnacipran. Additional studies comparing levomilnacipran ER to other commonly prescribed antidepressants are needed to further evaluate its place in therapy.
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Affiliation(s)
- Megan M. Saraceni
- St John Fisher College Wegmans School of Pharmacy, Rochester, NY, USA
| | - Jineane V. Venci
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Mona A. Gandhi
- St John Fisher College Wegmans School of Pharmacy, Rochester, NY, USA
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Gendelman SR, Lang DM. Specific immunotherapy in the treatment of atopic dermatitis: a systematic review using the GRADE system. Ann Allergy Asthma Immunol 2013; 111:555-61. [PMID: 24267368 DOI: 10.1016/j.anai.2013.08.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 08/11/2013] [Accepted: 08/22/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Controversy exists regarding the potential role of specific immunotherapy (SIT) as a therapeutic intervention for patients with atopic dermatitis (AD) and aeroallergen sensitivity. OBJECTIVE To critically appraise the evidence supporting the use of SIT for patients with AD and aeroallergen sensitivity. METHODS A literature search was performed using the terms immunotherapy plus atopic dermatitis and immunotherapy plus eczema. The same terms were used to search PubMed, Ovid, and Scopus. The limits were humans, English, and randomized controlled trial. Articles that were not in English or were observational in nature were excluded. These double-blinded randomized controlled trials were analyzed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS Seven articles fulfilled the inclusion characteristics; 1 involved sublingual SIT. All studies reported improvement in clinical symptoms of AD; however, studies differed in which type of patient (ie, with mild vs severe AD) benefited most from immunotherapy. Serious methodologic shortcomings were noted, including, but not limited to, many enrolled patients not completing participation; small study; and incomplete descriptions of randomization, blinding, allocation concealment, and/or data analysis not by intention to treat. CONCLUSION In a systematic review using the GRADE system, the strength of recommendation is weak for use of SIT in patients with AD. High-quality evidence from methodologically sound double-blinded randomized controlled trials is needed to support administration of SIT for patients with AD.
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Affiliation(s)
- Samantha R Gendelman
- Department of Clinical Immunology and Allergy, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California.
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Walker N, Howe C, Bullen C, Grigg M, Glover M, McRobbie H, Laugesen M, Parag V, Whittaker R. The combined effect of very low nicotine content cigarettes, used as an adjunct to usual Quitline care (nicotine replacement therapy and behavioural support), on smoking cessation: a randomized controlled trial. Addiction 2012; 107:1857-67. [PMID: 22594651 DOI: 10.1111/j.1360-0443.2012.03906.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine the combined effect of very low nicotine content (VLNC) cigarettes and usual Quitline care [nicotine replacement therapy (NRT) and behavioural support] on smoking abstinence, in smokers motivated to quit. DESIGN Single-blind, parallel randomized trial. SETTING New Zealand. PARTICIPANTS Smokers who called the Quitline for quitting support were randomized to either VLNC cigarettes to use whenever they had an urge to smoke for up to 6 weeks after their quit date, in combination with usual Quitline care (8 weeks of NRT patches and/or gum or lozenges, plus behavioural support) or to usual Quitline care alone. MEASUREMENTS The primary outcome was 7-day point-prevalence smoking abstinence 6 months after quit day. Secondary outcomes included continuous abstinence, cigarette consumption, withdrawal, self-efficacy, alcohol use, serious adverse events and views on the use of the VLNC cigarettes at 3 and 6 weeks and 3 and 6 months. FINDINGS A total of 1410 participants were randomized (705 in each arm), with a 24% loss to follow-up at 6 months. Participants in the intervention group were more likely to have quit smoking at 6 months compared to the usual care group [7-day point-prevalence abstinence 33 versus 28%, relative risk (RR) = 1.18, 95% confidence interval (CI): 1.01, 1.39, P = 0.037; continuous abstinence 23 versus 15%, RR = 1.50, 95% CI: 1.20, 1.87, P = 0.0003]. The median time to relapse in the intervention group was 2 months compared to 2 weeks in the usual care group (P < 0.0001). CONCLUSIONS Addition of very low nicotine content cigarettes to standard Quitline smoking cessation support may help some smokers to become abstinent.
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Affiliation(s)
- Natalie Walker
- Clinical Trials Research Unit, School of Population Health, The University of Auckland, Auckland, New Zealand.
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Nemzer BV, Rodriguez LC, Hammond L, Disilvestro R, Hunter JM, Pietrzkowski Z. Acute reduction of serum 8-iso-PGF2-alpha and advanced oxidation protein products in vivo by a polyphenol-rich beverage; a pilot clinical study with phytochemical and in vitro antioxidant characterization. Nutr J 2011; 10:67. [PMID: 21676230 PMCID: PMC3141640 DOI: 10.1186/1475-2891-10-67] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 06/15/2011] [Indexed: 11/21/2022] Open
Abstract
Background Measuring the effects of the acute intake of natural products on human biomarker concentrations, such as those related to oxidation and inflammation, can be an advantageous strategy for early clinical research on an ingredient or product. Methods 31 total healthy subjects were randomized in a double-blinded, placebo-controlled, acute pilot study with post-hoc subgroup analysis on 20 of the subjects. The study examined the effects of a single dose of a polyphenol-rich beverage (PRB), commercially marketed as "SoZo®", on serum anti-inflammatory and antioxidant markers. In addition, phytochemical analyses of PRB, and in vitro antioxidant capacity were also performed. Results At 1 hour post-intake, serum values for 8-iso-PGF2-alpha and advanced oxidation protein products decreased significantly by 40% and 39%, respectively. Additionally, there was a trend toward decreased C-reactive protein, and increased nitric oxide levels. Both placebo and PRB treatment resulted in statistically significant increases in hydroxyl radical antioxidant capacity (HORAC) compared to baseline; PRB showed a higher percent change (55-75% versus 23-74% in placebo group), but the two groups did not differ significantly from each other. Conclusions PRB produced statistically significant changes in several blood biomarkers related to antioxidant/anti-inflammatory effects. Future studies are justified to verify results and test for cumulative effects of repeated intakes of PRB. The study demonstrates the potential utility of acute biomarker measurements for evaluating antioxidant/anti-inflammatory effects of natural products.
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Singh AK. The FDA's perspective on the risk for rapid rise in hemoglobin in treating CKD anemia: Quo Vadis. Clin J Am Soc Nephrol 2010; 5:553-6. [PMID: 20203166 DOI: 10.2215/cjn.00490110] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Jensen MD, Bajnárek J, Lee SY, Nielsen S, Koutsari C. Relationship between postabsorptive respiratory exchange ratio and plasma free fatty acid concentrations. J Lipid Res 2009; 50:1863-9. [PMID: 19383980 DOI: 10.1194/jlr.m900021-jlr200] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The relationship between overnight postabsorptive (fasting) respiratory exchange ratio (RER) and plasma FFA concentrations was addressed using data from three separate protocols, each of which involved careful control of the antecedent diet. Protocol 1 examined the relationship between fasting RER and the previous daytime RER. In Protocol 2 fasting, RER and plasma palmitate concentrations were measured in 29 women and 31 men (body mass index <30 kg.m(-2)). Protocol 3 analyzed data from Nielsen et al. (Nielsen, S., Z. K. Guo, J. B. Albu, S. Klein, P. C. O'Brien, M. D. Jensen. 2003. Energy expenditure, sex and endogenous fuel availability in humans. J. Clin. Invest. 111: 981-988.) to understand how fasting RER and palmitate concentrations relate within individuals during four consecutive measurements. The results were as follows: 1) Fasting RER was correlated (r = 0.74, P < 0.001) with the previous day's average RER, and less so with RER variability. 2) Fasting RER was correlated (r = -0.39, P = 0.007) with fasting plasma palmitate concentrations. 3) The pattern of the RER/palmitate relationship was similar within individuals and between individuals; a negative slope was observed significantly more often than a positive slope (chi(2) test; P < 0.001). Our findings suggest that, despite a fixed food quotient, the slight departures from energy equilibrium in a controlled General Clinical Research Center environment can effect plasma FFA concentrations. We suggest that including indirect calorimetry as part of FFA metabolism studies may aid in data interpretation.
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Hernández-Molina G, Reichenbach S, Zhang B, Lavalley M, Felson DT. Effect of therapeutic exercise for hip osteoarthritis pain: results of a meta-analysis. ACTA ACUST UNITED AC 2008; 59:1221-8. [PMID: 18759315 DOI: 10.1002/art.24010] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Recommendations for lower extremity osteoarthritis (OA) and exercise have been primarily based on knee studies. To provide more targeted recommendations for the hip, we gathered evidence for the efficacy of exercise for hip OA from randomized controlled trials. METHODS A bibliographic search identified trials that were randomized, controlled, completed by >or=60% of subjects, and involved an exercise group (strengthening and/or aerobic) versus a non exercise control group for pain relief in hip OA. Two reviewers independently performed the data extraction and contacted the authors when necessary. Effect sizes (ES) of treatment versus control and the I(2) statistic to assess heterogeneity across trials were calculated. Trial data were combined using a random-effects meta-analysis. RESULTS Nine trials met the inclusion criteria (1,234 subjects), 7 of which combined hip and knee OA; therefore, we contacted the authors who provided the data on hip OA patients. In comparing exercise treatment versus control, we found a beneficial effect of exercise with an ES of -0.38 (95% confidence interval [95% CI] -0.68, -0.08; P = 0.01), but with high heterogeneity (I(2) = 75%) among trials. Heterogeneity was caused by 1 trial consisting of an exercise intervention that was not administered in person. Removing this study left 8 trials (n = 493) with similar exercise strategy (specialized hands-on exercise training, all of which included at least some element of muscle strengthening), and demonstrated exercise benefit with an ES of -0.46 (95% CI -0.64, -0.28; P < 0.0001). CONCLUSION Therapeutic exercise, especially with an element of strengthening, is an efficacious treatment for hip OA.
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Rabinowitz J, Davidson M. Risperidone versus haloperidol in long-term hospitalized chronic patients in a double blind randomized trial: a post hoc analysis. Schizophr Res 2001; 50:89-93. [PMID: 11378317 DOI: 10.1016/s0920-9964(00)00163-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients who remain in hospital for an extended time pose a special therapeutic challenge. OBJECTIVES The goal of this study was to examine whether the acute response of long-term hospitalized schizophrenic patients differs between haloperidol and risperidone based on a post hoc, sub-analysis of data from a large double blind pivotal trial. METHOD Data on chronic schizophrenic patients who had been hospitalized for at least 60 days (median 351 days) prior to entering this 8-week randomized double blind controlled trial were examined. This included 75 patients treated with 4 mg of risperidone and 69 treated with 10mg of haloperidol. Changes in symptoms were assessed with the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and the Clinical Global Impression (CGI). Data were analyzed using analysis of variance. RESULTS The analyses revealed that patients receiving risperidone improved significantly more than those treated with haloperidol. CONCLUSIONS Results suggest that the most often prescribed dose of risperidone, 4 mg, might be more effective for long-stay chronic schizophrenic patients than haloperidol 10mg.
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Abstract
Meta-analysis continues to grow in usage despite increased concern regarding its soundness. Over twenty meta-analyses directly pertain to vaccines. Vaccine researchers need to understand the technique as well as the criticisms. Meta-analysis involves four steps. First, the meta-analyst should establish certain criteria in advance of the second step where the meta-analyst gathers the data--the results of the individual studies. Third, the meta-analyst assesses the individual studies for combinability and, fourth, the meta-analyst actually combines the data to generate conclusions. Vaccine meta-analyses have addressed a variety of vaccines and a variety of study objectives including efficacy, immunogenicity and safety. Three classical concerns revolve around the issue of publication bias, data dredging and individual study variability. Additionally, vaccine meta-analyses suffer concerns particular to the field of vaccine research.
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Affiliation(s)
- R M Jacobson
- Mayo Vaccine Research Group, Department of Pediatric and Adolescent Medicine, Rochester, MN 55905-0001, USA.
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