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Zaragoza Domingo S, Alonso J, Ferrer M, Acosta MT, Alphs L, Annas P, Balabanov P, Berger AK, Bishop KI, Butlen-Ducuing F, Dorffner G, Edgar C, de Gracia Blanco M, Harel B, Harrison J, Horan WP, Jaeger J, Kottner J, Pinkham A, Tinoco D, Vance M, Yavorsky C. Methods for Neuroscience Drug Development: Guidance on Standardization of the Process for Defining Clinical Outcome Strategies in Clinical Trials. Eur Neuropsychopharmacol 2024; 83:32-42. [PMID: 38579661 DOI: 10.1016/j.euroneuro.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 04/07/2024]
Abstract
Neurosciences clinical trials continue to have notoriously high failure rates. Appropriate outcomes selection in early clinical trials is key to maximizing the likelihood of identifying new treatments in psychiatry and neurology. The field lacks good standards for designing outcome strategies, therefore The Outcomes Research Group was formed to develop and promote good practices in outcome selection. This article describes the first published guidance on the standardization of the process for clinical outcomes in neuroscience. A minimal step process is defined starting as early as possible, covering key activities for evidence generation in support of content validity, patient-centricity, validity requirements and considerations for regulatory acceptance. Feedback from expert members is provided, regarding the risks of shortening the process and examples supporting the recommended process are summarized. This methodology is now available to researchers in industry, academia or clinics aiming to implement consensus-based standard practices for clinical outcome selection, contributing to maximizing the efficiency of clinical research.
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Affiliation(s)
| | - Jordi Alonso
- Hospital del Mar Research Institute; CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III; Universitat Pompeu Fabra, Barcelona, Spain
| | - Montse Ferrer
- Hospital del Mar Research Institute; CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III; Universitat Pompeu Fabra, Barcelona, Spain
| | - Maria T Acosta
- National Human Genome Research Institute (NHGRI), NIH, Washington, USA
| | - Larry Alphs
- Denovo Biopharma, Princeton, New Jersey, USA
| | - Peter Annas
- Alexion Pharmaceuticals, Inc., Copenhagen, Denmark
| | | | | | | | | | | | | | | | - Brian Harel
- Takeda Pharmaceuticals USA Inc, Cambridge, MA, USA
| | | | | | | | - Jan Kottner
- Charité-Universitätsmedizin, Berlin, Germany
| | - Amy Pinkham
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Molin B, Zwedberg S, Berger AK, Sand A, Georgsson S. "The ignored pain" - experiences of encounters with healthcare from the perspective of women with pain persisting after childbirth - a qualitative study. Sex Reprod Healthc 2024; 39:100929. [PMID: 38041928 DOI: 10.1016/j.srhc.2023.100929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/25/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION Although the prevalence of pain persisting after pregnancy or labour decreases with time, up to 35 % of women report pain 8 months to 12 years after childbirth. To prevent the development and reduce the impact of chronic pain, researchers and clinicians emphasize the importance of early diagnosis as well as timely and appropriate treatment. Previous studies have shown that when women with post-childbirth morbidities consult healthcare professionals during the first year following birth, their problems are often neglected, and they do not receive adequate treatment. OBJECTIVE To explore how women with pain persisting for eight months after childbirth experienced encounters with healthcare. METHODS A descriptive qualitative design with 20 face-to-face, semi-structured interviews. Data were analysed using inductive qualitative content analysis. RESULTS "Pain ignored by healthcare" was identified as an essential theme and included four categories: "Questioned pain experience," "Inadequate pain management," "Lost in healthcare," and "Insufficient postpartum care " CONCLUSION: The women experienced that their pain was often not recognized or adequately treated, but instead ignored or trivialized. Recurring were descriptions of experienced knowledge gaps among the healthcare providers regarding pain and its management. There was an overall desire among women for a well-defined and well-functioning chain of care with better accessibility and scope.
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Affiliation(s)
- Beata Molin
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden.
| | - Sofia Zwedberg
- Theme Childreń s & Women's Health, PA Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Sand
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Georgsson
- The Swedish Red Cross University, Stockholm, Sweden; Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Pandina GJ, Busner J, Kempf L, Fallon J, Alphs LD, Acosta MT, Berger AK, Day S, Dunn J, Villalta-Gil V, Grabb MC, Horrigan JP, Jacobson W, Kando JC, Macek TA, Singh MK, Stanford AD, Domingo SZ. Ensuring Stakeholder Feedback in the Design and Conduct of Clinical Trials for Rare Diseases: ISCTM Position Paper of the Orphan Disease Working Group. Innov Clin Neurosci 2024; 21:52-60. [PMID: 38495603 PMCID: PMC10941866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The 1983 Orphan Drug Act in the United States (US) changed the landscape for development of therapeutics for rare or orphan diseases, which collectively affect approximately 300 million people worldwide, half of whom are children. The act has undoubtedly accelerated drug development for orphan diseases, with over 6,400 orphan drug applications submitted to the US Food and Drug Administration (FDA) from 1983 to 2023, including 350 drugs approved for over 420 indications. Drug development in this population is a global and collaborative endeavor. This position paper of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) describes some potential best practices for the involvement of key stakeholder feedback in the drug development process. Stakeholders include advocacy groups, patients and caregivers with lived experience, public and private research institutions (including academia and pharmaceutical companies), treating clinicians, and funders (including the government and independent foundations). The authors articulate the challenges of drug development in orphan diseases and propose methods to address them. Challenges range from the poor understanding of disease history to development of endpoints, targets, and clinical trials designs, to finding solutions to competing research priorities by involved parties.
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Affiliation(s)
- Gahan J. Pandina
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Pandina is with Janssen Research & Development in Titusville, New Jersey
| | - Joan Busner
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania and Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
| | - Lucas Kempf
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Kempf is with Parexel in Washington, DC
| | - Joan Fallon
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Fallon is with Curemark in Rye Brook, New York
| | - Larry D. Alphs
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Alphs is with Denovo Pharmaceuticals in Princeton, New Jersey
| | - Maria T. Acosta
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Acosta is with the National Institutes of Health in Bethesda, Maryland
| | - Anna-Karin Berger
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Berger is with H. Lundbeck A/S in Valby, Denmark
| | - Simon Day
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Day is with Clinical Trials Consulting & Training in Buckingham, United Kingdom
| | - Judith Dunn
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Dunn is with Evolution Research Group in Boston, Massachusetts
| | - Victoria Villalta-Gil
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Villalta-Gil is with WCG Clinical in Durham, North Carolina
| | - Margaret C. Grabb
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Grabb is with the National Institute of Mental Health in Rockville, Maryland
| | - Joseph P. Horrigan
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Horrigan is with AMO Pharma in Wonersh, United Kingdom and Duke University in Durham, North Carolina
| | - William Jacobson
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Jacobson is with Harmony Biosciences in Mundelein, Illinois
| | - Judith C. Kando
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Kando is with Karuna Therapeutics in Boston, Massachusetts
| | - Thomas A. Macek
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Macek is with Novartis Pharmaceuticals in Bannockburn, Illinois
| | - Manpreet K. Singh
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Singh is with Stanford University School of Medicine in Stanford, California
| | - Arielle D. Stanford
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Stanford is with Bristol Myers Squibb in Cambridge, Massachusetts
| | - Silvia Zaragoza Domingo
- All authors are members of the International Society for Central Nervous System Clinical Trials and Methodology (ISCTM) Working Group for Rare Disease/Orphan Drug Development. Drs. Pandina and Busner are Co-Chairs
- Dr. Domingo is with Neuropsynchro in Barcelona, Spain
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Raket LL, Hansen IH, Kühnel L, Åström DO, Berger AK, Krismer F, Wenning GK, Seppi K, Poewe W, Molinuevo JL. Reply to Letter to the Editor: "Disease Progression in Multiple System Atrophy: The Value of Clinical Cohorts with Long Follow-Up". Mov Disord 2023; 38:1569-1570. [PMID: 37565402 DOI: 10.1002/mds.29535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 08/12/2023] Open
Affiliation(s)
- Lars Lau Raket
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | - Line Kühnel
- BEC Financial Technologies, Roskilde, Denmark
| | | | | | - Florian Krismer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Gregor K Wenning
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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Krismer F, Palma JA, Calandra-Buonaura G, Stankovic I, Vignatelli L, Berger AK, Falup-Pecurariu C, Foubert-Samier A, Höglinger G, Kaufmann H, Kellerman L, Kim HJ, Klockgether T, Levin J, Martinez-Martin P, Mestre TA, Pellecchia MT, Perlman S, Qureshi I, Rascol O, Schrag A, Seppi K, Shang H, Stebbins GT, Wenning GK, Singer W, Meissner WG. The Unified Multiple System Atrophy Rating Scale: Status, Critique, and Recommendations. Mov Disord 2022; 37:2336-2341. [PMID: 36074648 PMCID: PMC9771866 DOI: 10.1002/mds.29215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 01/13/2023] Open
Abstract
The Unified Multiple System Atrophy (MSA) Rating Scale was developed to provide a surrogate marker of disease severity and clinical progression in patients with MSA. It is comprised of four subscales: UMSARS-I (12 items) rates patient-reported functional disability; UMSARS-II (14 items) assesses motor impairment based on a clinical examination; UMSARS-III records blood pressure and heart rate in the supine and standing positions; and UMSARS-IV (1 item) rates chore-based disability. Strengths of the UMSARS include its wide acceptance in the field, the comprehensive coverage of motor symptoms and its clinimetric properties (including reliability and validity). However, with its increasing use, potential areas of improvement in the UMSARS have become apparent. To address these limitations, a task force, involving clinicians, researchers, patient groups, and industry representatives, has recently been endorsed by the International Parkinson’s Disease and Movement Disorders Society. The present viewpoint summarizes strengths and weaknesses of the UMSARS and suggests a roadmap to develop an improved MSA clinical outcome assessment.
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Affiliation(s)
- Florian Krismer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Jose-Alberto Palma
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Giovanna Calandra-Buonaura
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Serbia
| | - Luca Vignatelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Anna-Karin Berger
- Clinical Science, Assessment and Innovation; Department of Clinical Development. Lundbeck, Valby, Denmark
| | - Cristian Falup-Pecurariu
- Department of Neurology, County Clinic Hospital, Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Alexandra Foubert-Samier
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, F-33000 Bordeaux, France
| | - Günter Höglinger
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany,Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Horacio Kaufmann
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Han-Joon Kim
- Department of Neurology and Movement Disorder Center, Seoul National University Hospital, Seoul, South Korea
| | - Thomas Klockgether
- Department of Neurology, University Hospital Bonn, Bonn, Germany,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Johannes Levin
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany,Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany,MODAG GmbH, Wendelsheim, Germany
| | - Pablo Martinez-Martin
- Center for Networked Biomedical Research in Neurodegenerative Diseases (CIBERNED), Carlos III Institute of Health. Madrid, Spain
| | - Tiago A. Mestre
- Parkinson’s Disease and Movement Disorders Center, Division of Neurology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa Brain and Mind Institute, Ottawa, Canada
| | - Maria Teresa Pellecchia
- Department of Medicine, Surgery and Dentistry, Neuroscience Section, University of Salerno, Salerno, Italy
| | - Susan Perlman
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Olivier Rascol
- French Reference Center for MSA, CIC 1436, NS-Park/FCRIN network and NeuroToul COEN Center, University Hospital of Toulouse, University of Toulouse 3 and INSERM, Toulouse, France
| | - Anette Schrag
- Department of Clinical Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, Rare Diseases Center, West China Hospital, Sichuan University, China
| | - Glenn T. Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Gregor K. Wenning
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Wassilios G. Meissner
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, F-33000 Bordeaux, France,Univ. Bordeaux, CNRS, IMN, UMR 5293, F-33000 Bordeaux, France,Dept. Medicine, University of Otago, Christchurch, and New Zealand Brain Research Institute, Christchurch, New Zealand
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Molin B, Zwedberg S, Berger AK, Sand A, Georgsson S. Disempowering women-a mixed methods study exploring informational support about pain persisting after childbirth and its consequences. BMC Pregnancy Childbirth 2022; 22:510. [PMID: 35739466 PMCID: PMC9229078 DOI: 10.1186/s12884-022-04841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Access to information is essential to achieving individual empowerment; meaning the ability to exercise control, manage one’s own condition and make informed decisions. However, studies have shown that information provided to women regarding physiological changes during the postpartum period and postpartum health was inadequate, incorrect, or inconsistent. Methods The aim of this study was to explore informational support about pain persisting after childbirth and its consequences. A sequential explanatory mixed methods design was used. In the first, quantitative phase, 1,171 women, who gave birth eight months earlier, completed a self-administered questionnaire. In the second, qualitative phase, 20 women who experienced chronic pain were interviewed. Descriptive statistics and qualitative content analysis were used to analyse the data. Results The majority of the women did not receive information about pain persisting after childbirth, or the information was insufficient or incorrect. They did not know when and where to seek help and did not consult health care professionals. In addition, the lack of information had a negative impact on women’s psychological well-being. All women expressed the need to be informed by health care professionals, irrespective of the individual risk of developing chronic pain. Conclusions Health services should ensure availability of information to give the women opportunity to achieve empowerment to make good health decisions, increase control over their health and well-being as well as to enhance their self-efficacy. We propose that a booklet or leaflet with relevant information about the risk of developing chronic pain, symptoms and treatment, along with advice about appropriate health care settings should be provided as part of antenatal or postnatal care.
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Affiliation(s)
- Beata Molin
- Department of Clinical Science Intervention and Technology (CLINTEC), Division of Obstetrics and Gynaecology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Huddinge, Sweden. .,Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden.
| | - Sofia Zwedberg
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden.,Theme Children's & Women's Health, PA Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Sand
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Georgsson
- Department of Clinical Science Intervention and Technology (CLINTEC), Division of Obstetrics and Gynaecology, Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Huddinge, Sweden.,The Swedish Red Cross University, Stockholm, Sweden
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Krismer F, Seppi K, Jönsson L, Åström DO, Berger AK, Simonsen J, Gordon MF, Wenning GK, Poewe W. Sensitivity to Change and Patient-Centricity of the Unified Multiple System Atrophy Rating Scale Items: A Data-Driven Analysis. Mov Disord 2022; 37:1425-1431. [PMID: 35332582 PMCID: PMC9543676 DOI: 10.1002/mds.28993] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background The Unified Multiple System Atrophy Rating Scale (UMSARS) is a commonly used semiquantitative rating scale to assess symptoms and measure disease progression in multiple system atrophy (MSA). However, it is currently incompletely understood which UMSARS items are the most sensitive to change and most relevant to the patient. Objective The objective of this study was to assess sensitivity to change and patient‐centricity of single UMSARS items. Methods Data were taken from the European Multiple System Atrophy Study Group Natural History Study and the Rasagiline for Multiple System Atrophy trial. Sensitivity of change of an item of the UMSARS was assessed by calculation of a sensitivity‐to‐change ratio using its mean slope of progression divided by the standard deviation of the slope when modeling its progression over time. Patient‐centricity was assessed through correlation of UMSARS items with quality‐of‐life measures. Results Progression rates above the mean in at least one of the two studies examined here were seen for seven items of UMSARS I and 11 items of UMSARS II. These items related to key motor functions such as swallowing, speech, handwriting, cutting food, hygiene, and dressing or walking, whereas items related to autonomic dysfunction were generally less sensitive to change in either data set. More UMSARS I items were identified as patient‐centric compared with UMSARS II items, and items most strongly impacting patients' quality of life were those affecting verbal communication skills, personal hygiene, and walking. Conclusion The present results illustrate the potential to optimize the UMSARS to enhance sensitivity to change and patient centricity. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Florian Krismer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Linus Jönsson
- Section for Neurogeriatrics, Department for Neurobiology, Care and Society, Karolinska Institutet, Stockholm, Sweden.,H. Lundbeck A/S, Valby, Denmark
| | | | | | | | | | - Gregor K Wenning
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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Busner J, Pandina G, Domingo S, Berger AK, Acosta MT, Fisseha N, Horrigan J, Ivkovic J, Jacobson W, Revicki D, Villalta-Gil V. Clinician- and Patient-reported Endpoints in CNS Orphan Drug Clinical Trials: ISCTM Position Paper on Best Practices for Endpoint Selection, Validation, Training, and Standardization. Innov Clin Neurosci 2021; 18:15-22. [PMID: 35096477 PMCID: PMC8794479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The International Society of CNS Clinical Trials Methodology (ISCTM) Working Group on Rare Disease/Orphan Drug Development is dedicated to improving and streamlining trials to best develop new treatments for rare diseases. The rarity of these disorders requires a drug development strategy that differs from those of nonrare conditions. Rare disease drug development programs are challenged with small sample sizes, heterogeneous clinical presentations, and few, if any, off-the-shelf endpoints. When disease-specific clinical endpoints exist, they might not be validated and are typically not well known or broadly used in clinical practice. This paper aims to provide an overview of the special issues surrounding endpoints in rare disease drug development, with guidance, practical applications, and discussion. DISCUSSION The paper covers regulatory considerations in endpoint selection; identification of relevant measurement domains; methods of quantifying clinical meaningfulness; incorporation of patient- and clinician-reported outcomes; considerations for global clinician- and patient-rated clinical assessments; cognition assessment challenges in rare diseases; translation considerations; training, standardization, and calibration of assessors; and endpoint quality assurance. Additionally, it provides guidance and resources for those involved in drug development for rare diseases. CONCLUSION In keeping with the mission of ISCTM and the rare disease/orphan drug development working group, this article is designed to encourage thoughtful consideration and provide insight and guidance to promote and further efforts in in central nervous system (CNS) rare disease drug development efforts.
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Affiliation(s)
- Joan Busner
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Gahan Pandina
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - SilviaZaragoza Domingo
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Anna-Karin Berger
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Maria T Acosta
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Nahome Fisseha
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Joseph Horrigan
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Jelena Ivkovic
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - William Jacobson
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Dennis Revicki
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
| | - Victoria Villalta-Gil
- All authors are members of the ISCTM Working Group for Rare Disease/Orphan Drug Development; Drs. Busner and Pandina are Co-Chairs
- Dr. Busner is with Signant Health in Blue Bell, Pennsylvania, and the Department of Psychiatry, Virginia Commonwealth University School of Medicine in Richmond, Virginia
- Dr. Pandina is with Janssen Pharmaceuticals in Titusville, New Jersey
- Dr. Domingo is with Neuorpsyncro in Barcelona, Spain. Dr. Berger is with Lundbeck in Copenhagen, Denmark
- Dr. Acosta is with National Human Genome Research Institute, National Institutes of Health, in Bethesda, Maryland
- Dr. Fisseha is with AbbVie Pharmaceuticals in North Chicago, Illinois
- Dr. Horrigan is with AMO Pharma Limited and the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, in Durham, North Carolina
- Dr. Ivkovic was with Lundbeck in Copenhagen, Denmark at the time this was written, but she is now with Zealand Pharma in Soborg, Denmark
- Dr. Jacobson is with Harmony Biosciences in Plymouth Meeting, Pennsylvania
- Dr. Revicki was with Evidera in Bethesda, Maryland
- Dr. Villalta-Gil is with VeraSci in Durham, North Carolina
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9
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Molin B, Zwedberg S, Berger AK, Sand A, Georgsson S. Grieving over the past and struggling forward - a qualitative study of women's experiences of chronic pain one year after childbirth. Midwifery 2021; 103:103098. [PMID: 34339902 DOI: 10.1016/j.midw.2021.103098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 06/21/2021] [Accepted: 07/03/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To describe women's experiences of chronic pain related to childbirth approximately one year after labour. DESIGN A qualitative design with face-to-face interviews analysed using inductive qualitative content analysis. PARTICIPANTS Twenty women who reported chronic pain, with onset during pregnancy and/or following labour, approximately one year after childbirth. FINDINGS The analysis revealed an essential theme, "Grieving over the past and struggling forward", and three categories "Mourning the losses", "Struggling with the present" and "Managing the future". CONCLUSIONS This study provides new knowledge about women's experiences of chronic pain one year after childbirth. The pain severely reduced women´s previous ability to perform physical and social activities, negatively impacted psychological well-being and altered their self-image. Most of the women adopted a positive attitude and hoped for improved health in the future, although constantly struggling with the pain and its consequences. IMPLICATIONS FOR PRACTICE This knowledge is particularly important as chronic pain may not diminish with time in predisposed individuals who may need help and support from health professionals in their endeavour to manage their pain. Healthcare providers, i.e. midwives, gynaecologists and general practitioners need to understand women´s experiences of chronic pain from their own perspective to improve identification and treatment of pain following childbirth, thus preventing women's suffering and potential long-term health problems. Future studies are warranted to further explore and discuss women's coping strategies, health seeking behaviour and experiences of health care.
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Affiliation(s)
- Beata Molin
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden; Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - Sofia Zwedberg
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden; Theme Children´ s & Women's Health, PA Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Sand
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Georgsson
- Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; The Swedish Red Cross University College, Stockholm, Sweden
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10
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Kühnel L, Berger AK, Markussen B, Raket LL. Simultaneous modeling of Alzheimer's disease progression via multiple cognitive scales. Stat Med 2021; 40:3251-3266. [PMID: 33853199 DOI: 10.1002/sim.8932] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 12/18/2020] [Accepted: 02/15/2021] [Indexed: 12/25/2022]
Abstract
Analyzing the progression of Alzheimer's disease (AD) is challenging due to lacking sensitivity in currently available measures. AD stages are typically defined based on cognitive cut-offs, but this results in heterogeneous patient groups. More accurate modeling of the continuous progression of the disease would enable more accurate patient prognosis. To address these issues, we propose a new multivariate continuous-time disease progression (MCDP) model. The model is formulated as a nonlinear mixed-effects model that aligns patients based on their predicted disease progression along a continuous latent disease timeline. The model is evaluated using long-term follow-up data from 2152 participants in the Alzheimer's Disease Neuroimaging Initiative. The MCDP model was used to simultaneously model three cognitive scales; the Alzheimer's Disease Assessment Scale-cognitive subscale, the Mini-Mental State Examination, and the Clinical Dementia Rating scale-sum of boxes. Compared with univariate modeling and previously proposed multivariate disease progression models, the MCDP model showed superior ability to predict future patient trajectories. Finally, based on the multivariate disease timeline estimated using the MCDP model, the sensitivity of the individual items of the cognitive scales along the different stages of disease was analyzed. The analysis showed that delayed memory recall items had the highest sensitivity in the early stages of disease, whereas language and attention items were sensitive later in disease.
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Affiliation(s)
- Line Kühnel
- H. Lundbeck A/S, Valby, Denmark.,Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Bo Markussen
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars L Raket
- H. Lundbeck A/S, Valby, Denmark.,Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
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11
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Molin B, Sand A, Berger AK, Georgsson S. Raising awareness about chronic pain and dyspareunia among women - a Swedish survey 8 months after childbirth. Scand J Pain 2020; 20:565-574. [PMID: 32383691 DOI: 10.1515/sjpain-2019-0163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/17/2020] [Indexed: 11/15/2022]
Abstract
Background and aims Although several studies have been conducted, knowledge about chronic pain and dyspareunia after childbirth is still limited. The aim of this study was to explore the prevalence of chronic pain 8 months after childbirth in a cohort of Swedish women. The characteristics of chronic pain, such as, pain intensity, localization and frequency as well as pain interference with daily activities were examined. An additional aim was to describe the prevalence and intensity of dyspareunia. Methods Data were obtained through two self-administered questionnaires and the patient record system, Obstetrix. The first questionnaire was distributed on the maternity ward, 24-36 h after labour, to Swedish-speaking women who had given birth to a living child (n = 1,507). The second questionnaire was sent by post 8 months after childbirth. We collected data about demographic and social characteristics, pain presence and its onset, as well as pain intensity, frequency, bodily localization and pain interference with activities of women's daily life. Results In total, 1,171 (77.7%) responded to both questionnaires and were included in the analysis. Eight months after giving birth, totally 16.7% (195/1,171) of the women reported chronic pain related to childbirth. Of these, 9.1% (106/1,171) of women reported chronic pain with onset during pregnancy, 4.5% (53/1,171) experienced chronic pain with onset following labour and 3.1% (36/1,171) of women had both chronic pain with onset during pregnancy and chronic pain with onset following labour (each participant could only appear in one of the groups). Women reported a lower prevalence of chronic pain after vaginal delivery than caesarean section (61/916, 6.7% vs. 28/255, 11%, p = 0.021, OR 1.73, 95% CI 1.1-2.8). Moreover, 19.2% (211/1,098) of women experienced dyspareunia. There was no difference regarding prevalence of dyspareunia and the mode of delivery. Of those women who had a vaginal delivery, 19.5% (167/858) experienced pain during intercourse and the corresponding number for women after caesarean section was 18.3% (44/240) (p = 0.694, OR 0.929, CI 0.6-1.3). Approximately 80% of women with chronic pain, and 60% of women that experienced dyspareunia, rated their worst pain as moderate or severe (NRS 4-10). The corresponding number regarding average chronic pain was between 50 and 70%. More than 35% of the women with chronic pain scored pain interference with daily activities as ≥4 on a 0-10 NRS. Conclusions In our study, chronic pain 8 months after childbirth was reported by one in six women and one in five of the women experienced dyspareunia. The intensity of both chronic pain and dyspareunia was reported as moderate to severe in a significant proportion of women and chronic pain interfered considerably with daily activities. Implications There is a need to raise awareness among healthcare providers of this clinical problem as well as to revise and upgrade education regarding pain after childbirth to prevent potential long-term health problems, women's suffering and increased need for health care. The development of strategies for prevention, follow-up and treatment of pain is warranted. More research, including women's experiences of pain as well as intervention studies, are also needed.
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Affiliation(s)
- Beata Molin
- Department of Clinical Science Intervention and Technology (CLINTEC), Division of Obstetrics and Gynaecology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.,Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
| | - Anna Sand
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Susanne Georgsson
- The Swedish Red Cross University College, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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12
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Ingelgard AP, Nokela M, Cole JC, Berger AK. Patient-Reported Outcomes (Pro) in Go/No-Go Decision Making in Drug Development. Value Health 2014; 17:A521. [PMID: 27201631 DOI: 10.1016/j.jval.2014.08.1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | - M Nokela
- Covance Market Access Services, Solna, Sweden
| | - J C Cole
- Covance Market Access Services, Inc., San Diego, CA, USA
| | - A K Berger
- Covance Market Access Services, Inc., San Diego, CA, USA
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13
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Abstract
Systemic chemotherapy, targeted therapies and radiotherapy for patients with malignant tumors lead to unfavorable surgical conditions with increased risks of postoperative complications. For gastric cancer and cancer of the esophagogastric junction, surgery after neoadjuvant treatment is associated with a mortality of approximately 5 %. Given the increase in metastatic surgery for colorectal carcinoma, surgeons should be aware of the specific side effects of therapeutic drugs to ensure an optimal course of treatment. The impact of chemotherapy-induced hepatic lesions on postoperative development is unclear. Bevacizumab treatment should be stopped at least 5 weeks before surgery to reduce the risk of thromboembolic events, bleeding and wound healing complications. Immunosuppressive and immunomodulating agents alter wound healing and preoperative alterations should be carefully evaluated. For patients with chronic corticosteroid therapy, perioperative supplementation should be considered when planning surgery as well as routine dosages.
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Affiliation(s)
- A K Berger
- Medizinische Onkologie, Nationales Centrum für Tumorerkrankungen Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Deutschland
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14
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Hierner R, Berger AK. Did the partial contralateral C7-transfer fulfil our expectations? Results after 5 year experience. Acta Neurochir Suppl 2011; 100:33-5. [PMID: 17985541 DOI: 10.1007/978-3-211-72958-8_7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Within the last decade contralateral C7-transfer has become a new source of axon donor in complete brachial plexus lesions. METHODS Ten adult patients with a complete posttraumatic brachial plexus lesion and a follow-up of more than 5 years are analyzed. As shown by GU we are using a two stage procedure with exploration and extraplexuel neurotization of the suprascapular nerve using 1/2 spinal acessory nerve. Depending on the intraoperative findings, the musculocutaneous nerve is neurotized by the phrenic nerve at the time of primary operation or secondarily neurotized by the contralateral C7 root. If the musculocutaneous nerve could be neurotized by the phrenic nerve, C7-transfer is used to reinnervate the median nerve. If ever possible, the vascularized ulnar nerve graft or if not availabe two sural nerves are used. Neurotization of the musculocutaneous nerve was carried out in 6, and of the median nerve in 4 patients. There are 6 patients in the MC group and 4 patients in the Median group. Criterias for evaluation used are: donor site (morbidity, classification), time for recovery, time for autonomization, and functional result. Successful elbow flexion is achieved if muscle power > M3, successful median nerve motor function is achieved if a primitive power grip pattern is achieved. RESULTS All patients were complaining of temporary paresthesia in the dorsal part of P3 of the thumb, index and middle finger. There was complete sensory at the 3-month postoperative examination. There was no evident clinical motor loss at the donor extremity. A successful elbow flexion, i.e. muscle power > M3 was achieved in all 6 patients after 9-15 months. 4 of 6 patients are able to use this function individually. In the other two patients a start command must be given voluntarily from the contralateral side (contraction of the contralateral latissimus dorsi muscle). A functional primitive grip pattern could be achieved in 1 out of 4 patients after 18 months. In three patients, although there is movement, this mouvement must be judged "academic" at the present state. CONCLUSIONS The C7-transfer proved to be a safe transfer if at the time of operation no fascicles innervating wrist and finger extension are taken. Provided adequate biceps muscle organ function, active elbow flexion can be reconstructed in most of the patients. However, for median nerve reinnervation motor results are moderate up to now.
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Affiliation(s)
- R Hierner
- Plastic, Reconstructive and Aesthetic Surgery, Center for Interdisciplinary Reconstructive Surgery, Microsurgery, Hand Surgery, Burns, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium.
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15
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Livner A, Berger AK, Karlsson S, Backman L. Differential effects of depressive symptoms on prospective and retrospective memory in old age. J Clin Exp Neuropsychol 2008; 30:272-9. [PMID: 17852610 DOI: 10.1080/13803390701380591] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The effects of depressive symptoms on prospective and retrospective memory were examined in a population-based sample of elderly persons (n = 404). Depression was assessed using the Comprehensive Psychopathological Rating Scale and treated as a continuous variable. The variation in depressive symptoms ranged from no symptoms to presence of a clinical depression. Depressive symptoms had a negative effect on consolidation and retrieval in retrospective memory. However, the retrospective, but not the prospective, component of prospective memory was affected by depression. The findings are discussed in light of medial-temporal lobe alterations in depression.
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Affiliation(s)
- Asa Livner
- Aging Research Center, Division of Geriatric Epidemiology, NVS, Karolinska Institutet, Gävlegatan 16 S-113 30 Stockholm, Sweden.
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16
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Abstract
In a retrospective clinical study 16 vascularized joint transfers to the hand with an average follow-up of 8.2 (3 - 15) years were evaluated. The finger joint defect was caused by trauma in 12 patients, tumour in 2 patients and infection and congenital deformity in 1 patient each. There were 14 men and 2 women. The mean age range was 26 (2 - 42) years. In 6 cases a partial vascularized joint transfer was carried out, with the transplant being harvested in two cases from non-replantable finger according to the "tissue bank concept" according to Chase and in the other two cases from the PIP-joint of the second toe. In 10 patients a complete vascularized joint transfer was carried out, with the joint being harvested from the hand in 6 cases and from the 2nd toe in 4 cases. The following criteria were evaluated: active range of motion (neutral-0-method), postoperative arthritis, growth and complications. Active range of motion of the transplanted joint was for partial PIP-joint transfer Ex/Flex 0/20/65 degrees und for partial MP-joint transfer 0/20/30 degrees . After DIP-to-PIP-joint transposition active range of motion was measured Ex/Flex 0/20/60 degrees , after PIP-to-PIP transposition 0/30/60 degrees , PIP-to-MP-transposition 0/20/80 degrees and after MP-to-MP-transposition 0/20/57 degrees . The results after microvascular PIP-joint transfer from the 2nd toe for PIP-joint reconstruction were 0/25/58 degrees for PIP-joint reconstruction and 0/15/70 degrees for MP-joint reconstruction. Arthritic changes could be seen in 3 out of 4 patients with partial vascularized joint transfer. In all complete joint transfers there was no clinical and radiological evidence of arthritis even after 15 years. In the two skeletal immature patients at the time of transfer, normal growth compared to the contralateral donor site could be seen. In 8 out of 14 patients complications occurred. In 4 cases tendolysis of the extensor tendon was necessary. In 4 patients skeletal malalignment (3 x sagittal plane, 1 x rotation) was diagnosed. In one patient flexor pulley reconstruction was necessary in order to correct a bowstring deformity. Indications for vascularized joint transfer at the finger in children is set because of lack of therapy option offering normal growth potential. In adults vascularized joint transfer is indicated in case of contraindication for prosthetic joint replacement or arthrodesis.
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Affiliation(s)
- R Hierner
- Plastische, Rekonstruktive und Asthetische Chirurgie, Zentrum für Interdisziplinäre Rekonstruktive Chirurgie, Katholische Universität Leuven, Universitätsklinikum Gasthuisberg, Herestraat 49, 3000 Leuven, Belgien.
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17
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Palmer K, Berger AK, Monastero R, Winblad B, Bäckman L, Fratiglioni L. Predictors of progression from mild cognitive impairment to Alzheimer disease. Neurology 2007; 68:1596-602. [PMID: 17485646 DOI: 10.1212/01.wnl.0000260968.92345.3f] [Citation(s) in RCA: 258] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the occurrence of neuropsychiatric symptomatology and the relation to future development of Alzheimer disease (AD) in persons with and without mild cognitive impairment (MCI). METHOD We followed 185 persons with no cognitive impairment and 47 with MCI (amnestic and multidomain), ages 75 to 95, from the population-based Kungsholmen Project, Stockholm, Sweden, for 3 years. Three types of neuropsychiatric symptoms were assessed at baseline: mood-related depressive symptoms, motivation-related depressive symptoms, and anxiety-related symptomatology. AD at 3-year follow-up was diagnosed according to Diagnostic and Statistical Manual for Mental Disorders-III-R criteria. RESULTS Psychiatric symptoms occurred more frequently in persons with MCI (36.2% mood, 36.2% motivation, and 46.8% anxiety symptoms) than in cognitively intact elderly individuals (18.4% mood, 13.0% motivation, and 24.9% anxiety). Of persons with both MCI and anxiety symptoms, 83.3% developed AD over follow-up vs 6.1% of cognitively intact persons and 40.9% persons who had MCI without anxiety. Among persons with MCI, the 3-year risk of progressing to AD almost doubled with each anxiety symptom (relative risk [RR] = 1.8 [1.2 to 2.7] per symptom). Conversely, among cognitively intact subjects, only symptoms of depressive mood were related to AD development (RR = 1.9 [1.0 to 3.6] per symptom). CONCLUSIONS The predictive validity of mild cognitive impairment (MCI) for identifying future Alzheimer disease (AD) cases is improved in the presence of anxiety symptoms. Mood-related depressive symptoms (dysphoria, suicidal ideation, etc.) in preclinical AD might be related to the neuropathologic mechanism, as they appear preclinically in persons both with and without MCI.
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Affiliation(s)
- K Palmer
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden.
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18
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Abstract
To determine the size of the impairment across different cognitive domains in preclinical Alzheimer's disease (AD), a meta-analysis based on 47 studies involving 9,097 controls and 1,207 preclinical AD cases was conducted. There were marked preclinical deficits in global cognitive ability, episodic memory, perceptual speed, and executive functioning; somewhat smaller deficits in verbal ability, visuospatial skill, and attention; and no preclinical impairment in primary memory. Younger age (< 75 years) and shorter follow-up intervals (< 3 years) were associated with larger effect sizes for both global cognitive ability and episodic memory. For global cognitive ability, studies that used population-based sampling yielded larger effect sizes; for episodic memory, larger differences were seen in studies that preidentified groups in terms of baseline cognitive impairment. Within episodic memory, delayed testing and recall-based assessment resulted in the largest effect sizes. The authors conclude that deficits in multiple cognitive domains are characteristic of AD several years before clinical diagnosis. The generalized nature of the deficit is consistent with recent observations that multiple brain structures and functions are affected long before the AD diagnosis.
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Affiliation(s)
- Lars Bäckman
- Aging Research Center, Division of Geriatric Epidemiology, Neurotec, Karolinska Institute, Stockholm, Sweden.
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Abstract
Both Alzheimer's disease (AD) and depression (D) are prevalent disorders in old age and may co-occur in the same individual. The present study examined whether a diagnosis of D in AD has negative effects on cognitive functioning in the preclinical stage of the diseases, as well as at the time when the diagnoses were rendered. Population-based samples of 13 individuals with incident AD and D, 109 incident AD cases without D, and 179 normal older adults were followed over a three-year period. The groups were compared preclinically and at the time of diagnosis on global cognitive functioning using the MMSE total and the specific item scores, as well as the occurrence of depressive symptoms. As expected, there were clear AD-related deficits preclinically, which were exacerbated at follow-up. In addition, there were D-related deficits on three MMSE items (i.e., following commands, reading, and writing). The poorer performance on the three MMSE items was linked to an elevation of depressive symptoms. However, D was not associated with greater decline in cognitive functioning over the three-year follow-up period. Thus, although depressive symptoms may result in slight cognitive deficits in preclinical AD, at the time of the dementia diagnosis these effects may be absorbed by the neurodegenerative process.
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Affiliation(s)
- Anna-Karin Berger
- Aging Research Center--ARC, Division of Geriatric Epidemiology, NEUROTEC, Karolinska Institute, Stockholm.
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20
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Abstract
We examined whether a diagnosis of depression affects verbal and visuospatial performance in Alzheimer's disease (AD). Using data from a population-based study, persons with AD and depression (AD/D), AD alone and a control group of normal older adults were compared in two tests of verbal ability (category and letter fluency) and two tests of visuospatial skill (block design and clock drawing). As expected, there were clear AD-related deficits across all cognitive tasks. More importantly, the AD and AD/D groups were indistinguishable on all task variables. The lack of effects of depression was discussed relative to the view that those symptoms of this disease which are especially detrimental to cognitive functioning (e.g. concentration difficulties, lack of interest, loss of energy) may already be present in AD as a result of the neurodegenerative process.
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Affiliation(s)
- Anna-Karin Berger
- Stockholm Gerontology Research Center and Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research (Neurotec), Division of Geriatric Medicine, Karolinska Institute, Stockholm, Sweden.
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Vaccarino V, Berger AK, Abramson J, Black HR, Setaro JF, Davey JA, Krumholz HM. Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. Am J Cardiol 2001; 88:980-6. [PMID: 11703993 DOI: 10.1016/s0002-9149(01)01974-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pulse pressure has been related to higher risk of cardiovascular events in older persons. Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure. Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure. Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension, and the influence of treatment on the pulse pressure effect. We assessed the relation between pulse pressure, measured throughout the follow-up period, and the incidence of coronary heart disease (CHD), heart failure (HF), and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program, a 5-year randomized, placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults. In the treatment group, a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32% increase in risk of HF and a 24% increase in risk of stroke after controlling for systolic blood pressure and other known risk factors, as well as with a 23% increase in risk of HF and a 19% increase in risk of stroke after controlling for diastolic blood pressure and other risk factors. Pulse pressure was not significantly associated with HF or stroke in the placebo group, nor with incidence of CHD in either the placebo or treatment group. These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension.
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Affiliation(s)
- V Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30306, USA.
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22
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Berger AK, Breall JA, Gersh BJ, Johnson AE, Oetgen WJ, Marciniak TA, Schulman KA. Effect of diabetes mellitus and insulin use on survival after acute myocardial infarction in the elderly (the Cooperative Cardiovascular Project). Am J Cardiol 2001; 87:272-7. [PMID: 11165959 DOI: 10.1016/s0002-9149(00)01357-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Using data from a retrospective cohort study of Medicare beneficiaries hospitalized with an acute myocardial infarction (AMI), we evaluated the role of diabetes mellitus on 30-day and 1-year mortality. We classified subjects as nondiabetics, diabetics controlled with diet alone, diabetics receiving an oral hypoglycemic agent, and diabetics on insulin at time of admission. We compared baseline admission characteristics of subgroups using chi-square and Wilcoxon rank-sum tests and evaluated the effect of each diabetic state using sequential logistic models. We identified 80,832 nondiabetic patients, 9,862 diet-controlled diabetic patients, 14,664 diabetics receiving an oral hypoglycemic agent, and 12,241 diabetic patients on insulin therapy. Although mean age was similar among the groups, prevalence of hypertension, prior AMI, prior congestive heart failure, and prior revascularization were higher among diabetic patients, particularly those taking insulin. Diabetic patients, particularly those taking insulin, were less likely to receive aspirin and beta blockers and to undergo coronary revascularization. Diabetic patients had higher 30-day and 1-year mortality than nondiabetic patients. After adjustment for demographics, clinical and hospital characteristics, and treatment strategies, insulin-treated diabetics had the highest risk of mortality, followed by diabetics receiving oral hypoglycemic agents, followed by diet-controlled diabetics. Thus, diabetes is highly prevalent among elderly patients with an AMI. Mortality rates for these patients, particularly insulin-using diabetics, are higher than among their nondiabetic counterparts. Preventive and therapeutic strategies must be developed to ensure improved short- and long-term outcomes for elderly patients with diabetes and AMI.
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Affiliation(s)
- A K Berger
- Division of Cardiology, Yale-New Haven Medical Center, Connecticut, USA
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Rathore SS, Berger AK, Weinfurt KP, Feinleib M, Oetgen WJ, Gersh BJ, Schulman KA. Race, sex, poverty, and the medical treatment of acute myocardial infarction in the elderly. Circulation 2000; 102:642-8. [PMID: 10931804 DOI: 10.1161/01.cir.102.6.642] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Race, sex, and poverty are associated with the use of diagnostic cardiac catheterization and coronary revascularization during treatment of acute myocardial infarction (AMI). However, the association of sociodemographic characteristics with the use of less costly, more readily available medical therapies remains poorly characterized. METHODS AND RESULTS We evaluated 169 079 Medicare beneficiaries >/=65 years of age treated for AMI between January 1994 and February 1996 to determine the association of patient race, sex, and poverty with the use of medical therapy. Multivariable regression models were constructed to evaluate the unadjusted and adjusted influence of sociodemographic characteristics on the use of 2 admission (aspirin, reperfusion) and 2 discharge therapies (aspirin, beta-blockers) indicated during the treatment of AMI. Therapy use varied by patient race, sex, and poverty status. Black patients were less likely to undergo reperfusion (RR 0.84, 95% CI 0. 78, 0.91) or receive aspirin on admission (RR 0.97, 95% CI 0.96, 0. 99) and beta-blockers (RR 0.94, 95% CI 0.88, 1.00) at discharge. Female patients were less likely to receive aspirin on admission (RR 0.98, 95% CI 0.97, 0.99) and discharge (RR 0.98, 95% CI 0.96, 0.99). Poor patients were less likely to receive aspirin (RR 0.97, 95% CI 0. 96, 0.98) or reperfusion (RR 0.97, 95% CI 0.93, 1.00) on admission and aspirin (RR 0.98, 95% CI 0.96, 1.00), or beta-blockers (RR 0.95, 95% CI 0.91, 0.99) on discharge. CONCLUSIONS Medical therapies are currently underused in the treatment of black, female, and poor patients with AMI.
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Affiliation(s)
- S S Rathore
- Clinical Economics Research Unit, Georgetown University Medical Center, Washington, DC, USA
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Abstract
OBJECTIVES We compared outcomes following thrombolytic therapy and primary angioplasty with no reperfusion therapy in a population-based cohort of older patients presenting with acute myocardial infarction (AMI) and indications for acute reperfusion. BACKGROUND Evidence supporting the efficacy of acute reperfusion (thrombolytic therapy or primary angioplasty) in the elderly with suspected AMI is not as strong as it is in younger groups. METHODS From a national cohort of Medicare beneficiaries with AMI, we identified 37,983 patients age 65 or older who presented within 12 h of symptom onset with ST elevation or left bundle branch block. A total of 14,341 (37.8%) received thrombolytic therapy and 1,599 (4.2%) underwent primary angioplasty within 6 h of hospital arrival. RESULTS After adjustment for demographic, clinical, hospital and physician factors, and co-interventions, thrombolytic therapy was not associated with a better 30-day survival (odds ratio [OR] 1.01; 95% confidence interval [CI]: 0.94 to 1.09) compared with no therapy, whereas primary angioplasty was (OR 0.79; 95% CI: 0.66 to 0.94). At one year, both thrombolytic therapy (OR 0.84; 95% CI: 0.79 to 0.89) and primary angioplasty (OR 0.71; 95% CI: 0.61 to 0.83) were associated with a survival benefit. CONCLUSIONS In this national sample of older patients, those who received thrombolytic therapy or primary angioplasty had lower mortality at one year compared with those who did not receive a reperfusion strategy. However, only primary angioplasty was associated with better survival at 30 days. Our findings should heighten interest in further investigating the best approach to the treatment of older patients with suspected AMI and ST segment elevation or left bundle branch block.
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Affiliation(s)
- A K Berger
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA
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Berger AK, Radford MJ, Krumholz HM. Factors associated with delay in reperfusion therapy in elderly patients with acute myocardial infarction: analysis of the cooperative cardiovascular project. Am Heart J 2000; 139:985-92. [PMID: 10827378 DOI: 10.1067/mhj.2000.105703] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Many elderly patients with an acute myocardial infarction (AMI) do not receive thrombolysis within 30 minutes of hospital arrival as recommended by the American College of Cardiology/American Heart Association Guidelines. We sought to identify factors associated with delay in administration of thrombolysis after arrival to the hospital in these patients and to determine whether this delay is associated with increased mortality rates. METHODS AND RESULTS By using the Cooperative Cardiovascular Project database, we identified patients who received thrombolysis for an AMI. The patients were stratified into groups by time to thrombolysis after hospital arrival. Among a cohort of 17,379 patients, 22.2% received thrombolysis in the first 30 minutes after hospital arrival. Patients treated after the first 30 minutes were more likely to be older, be female, be diabetic, have a history of hypertension or heart failure, and have less marked ST elevation. They were also more likely to be admitted to smaller hospitals with a lower volume of AMIs and to hospitals without a cardiac catheterization laboratory. The 30-day mortality rate was significantly lower for patients treated within the first 30 minutes. After adjustments were made for clinical and hospital characteristics, delays in therapy beyond 30 and 90 minutes were associated with an increase in 1-year mortality rates of 9% and 27%, respectively, compared with delays for patients treated within 30 minutes. CONCLUSIONS After hospital arrival, time to treatment with thrombolytic therapy is longer than recommended in a significant proportion of patients. Clinical characteristics and institutional factors are associated with the delay in treatment. The more rapid treatment of appropriate elderly patients with an AMI probably will reduce mortality rates.
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Affiliation(s)
- A K Berger
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT 06520-8025, USA
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Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ, Solomon AJ. Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation 2000; 101:969-74. [PMID: 10704162 DOI: 10.1161/01.cir.101.9.969] [Citation(s) in RCA: 213] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although atrial fibrillation (AF) is a common complication of acute myocardial infarction (MI), patient characteristics and association with outcomes remain poorly defined in the elderly. METHODS AND RESULTS We evaluated 106 780 Medicare beneficiaries > or =65 years of age from the Cooperative Cardiovascular Project treated for acute MI between January 1994 and February 1996 to determine the prevalence and prognostic significance of AF complicating acute MI in elderly patients. Patients were categorized on the basis of the presence of AF, and those with AF were further subdivided by time of AF (present on arrival versus developing during hospitalization). AF and non-AF patients were compared by univariate analysis, and logistic regression modeling was used to identify clinical predictors of AF. The influence of AF on outcomes was evaluated by unadjusted Kaplan-Meier survival curves and logistic regression models. AF was documented in 23 565 patients (22. 1%): 11 510 presented with AF and 12,055 developed AF during hospitalization. AF patients were older, had more advanced heart failure, and were more likely to have had a prior MI and undergone coronary revascularization. AF patients had poorer outcomes, including higher in-hospital (25.3% versus 16.0%), 30-day (29.3% versus 19.1%), and 1-year (48.3% versus 32.7%) mortality. AF remained an independent predictor of in-hospital (odds ratio [OR], 1. 21), 30-day (OR, 1.20), and 1-year (OR, 1.34) mortality after multivariate adjustment. Patients developing AF during hospitalization had a worse prognosis than patients who presented with AF. CONCLUSIONS AF is a common complication of acute MI in elderly patients and independently influences mortality, particularly when it develops during hospitalization.
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Affiliation(s)
- S S Rathore
- Clinical Economics Research Unit, Georgetown University Medical Center, Washington, DC 20007, USA
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Abstract
BACKGROUND Atrial fibrillation is a common complication of cardiovascular surgery. Beta-blockers have been shown to decrease the incidence of postoperative atrial fibrillation. However, the use of magnesium is more controversial. It was our hypothesis that adjunctive magnesium sulfate would improve the efficacy of beta-blockers alone in the prevention of postoperative atrial fibrillation. METHODS We prospectively randomized 167 coronary artery bypass patients (mean age 61+/-10 years, 115 men) to receive propranolol alone (20 mg four times daily) or propranolol and magnesium (18 g over 24 hours). Magnesium was begun intraoperatively, and propranolol was started on admission to the intensive care unit. RESULTS Using an intention-to-treat analysis, the incidence of postoperative atrial fibrillation was 19.5% in the propranolol-treated patients and 22.4% in propranolol + magnesium-treated patients (p = 0.65). Because combination therapy resulted in an excess of postoperative hypotension, which required withholding doses of propranolol, an on-treatment analysis was also performed. In this analysis, the incidence of atrial fibrillation was still not significantly different (18.5% in propranolol-treated patients and 10.0% in propranolol + magnesium-treated patients, p = 0.20). CONCLUSIONS Adjunctive magnesium sulfate, in combination with propranolol, does not decrease the incidence of postoperative atrial fibrillation.
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Affiliation(s)
- A J Solomon
- Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA.
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Berger AK, Fratiglioni L, Forsell Y, Winblad B, Bäckman L. The occurrence of depressive symptoms in the preclinical phase of AD: a population-based study. Neurology 1999; 53:1998-2002. [PMID: 10599771 DOI: 10.1212/wnl.53.9.1998] [Citation(s) in RCA: 179] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine preclinical depressive symptoms 3 years before the diagnosis of AD. METHODS The authors compared incident AD patients and nondemented individuals in terms of baseline mood- and motivation-related symptoms of depression, and assessed whether depressive symptoms in preclinical AD are related to self-perceived memory problems. Participants came from a population-based longitudinal study on aging and dementia in Stockholm, Sweden. The sample consisted of 222 persons older than 74 years who were followed for a 3-year interval. Thirty-four individuals had developed AD at follow-up, whereas 188 remained nondemented. Dementia diagnosis was made according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised. Depressive symptoms were assessed by the Comprehensive Psychopathological Rating Scale. RESULTS The incident AD patients had more depressive symptoms than the nondemented persons at baseline. There was a dominance of motivation-related symptoms of depression (e.g., lack of interest, loss of energy, concentration difficulties) in preclinical AD. This association remained when adjusting for subjective memory complaints. CONCLUSIONS Depressive symptoms are elevated preclinically in AD, and this elevation is not merely a by-product of self-perceived cognitive difficulties. Thus, depressive symptoms may be part of the preclinical phase in AD.
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Affiliation(s)
- A K Berger
- Stockholm Gerontology Research Center and Department of Clinical Neuroscience, Occupational Therapy, and Elderly Care Research, Karolinska Institute, Stockholm, Sweden
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Abstract
OBJECTIVES This study sought to determine whether statistical analysis of a computerized clinical diagnostic database can be used as a tool for quality assessment by determining the contribution of reader bias to variance in diagnostic output. BACKGROUND In industry, measurement of product uniformity is a key component of quality assessment. In echocardiography, quality assessment has focused on review of small numbers of cases, or prospective determination of reader variability in selected and relatively small subsets. However, diagnostic biases in clinical practice might be discerned utilizing large computerized databases to determine interreader differences in diagnostic prevalence and, with use of appropriate statistical methods, to determine the association of reader selection with diagnostic prevalence independently of other covariates. METHODS We analyzed 6,026 echocardiograms in a computerized database, read by one of three level 3 (American Society of Echocardiography) readers, for differences in frequency among four coded echocardiographic diagnoses: mitral valve prolapse, valvular vegetations, left ventricular (LV) thrombus, and LV regional wall-motion abnormality. RESULTS Significant differences (up to fourfold) were found between readers, which persisted after statistical adjustment for those population characteristics, which differed slightly between readers. The low population prevalence of these conditions would have made it unlikely that these interreader differences could be detected by nonstatistical methods. Additionally, chamber dimensions differed between readers and were not normally distributed. CONCLUSIONS Statistically based quality assessment analysis of computerized clinical databases facilitates ongoing monitoring of interreader bias despite low diagnostic prevalence, and targets opportunities for subsequent quality improvement.
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Affiliation(s)
- A K Berger
- Division of Cardiology, Georgetown University Medical Center, Georgetown University, Washington, DC, USA
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Abstract
In a population-based study of persons between 75 and 96 years of age, normal old adults (n = 296), patients with Alzheimer's disease (AD; n = 45), and patients with concomitant AD and depression (AD-D; n = 9) were compared on free recall and recognition of slowly and rapidly presented words and digit span. With the exception of forward digit span, the normal old group outperformed the 2 AD groups across all tasks. In free recall, only the normal old group performed better as task pacing decreased; however, all groups benefited from more study time in recognition. This suggests that both AD and AD-D patients have deficits in the ability to use more study time for remembering. Of most importance, the 2 AD groups were indistinguishable for all task variables. This lack of comorbidity effects is discussed relative to the view that depression, much like many other individual-difference variables that affect memory performance in normal aging, may be overshadowed by the influence of the neurodegenerative process in AD.
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Affiliation(s)
- K Fahlander
- Stockholm Gerontology Research Center and Karolinska Institute, Sweden
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Berger AK, Schulman KA, Gersh BJ, Pirzada S, Breall JA, Johnson AE, Every NR. Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients. JAMA 1999; 282:341-8. [PMID: 10432031 DOI: 10.1001/jama.282.4.341] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known. OBJECTIVE To determine survival after primary PTCA vs thrombolysis in elderly patients. DESIGN The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files. SETTING Acute care hospitals in the United States. PATIENTS A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy. MAIN OUTCOME MEASURES Thirty-day and 1-year survival. RESULTS A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08). CONCLUSION In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.
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Affiliation(s)
- A K Berger
- Institute for Cardiovascular Sciences, Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA
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Abstract
OBJECTIVE The authors' goal was to examine whether individuals diagnosed as having major depression experienced greater levels of depressive symptoms and cognitive dysfunction up to 3 years before the clinical diagnosis was rendered. METHOD The study included 185 subjects 75 years old or older who participated in a population-based longitudinal survey in Stockholm. Ten of the subjects were diagnosed as depressed up to 3 years after initial screening, and these individuals were compared with the 175 subjects who were not depressed at 3-year follow-up. Depression was diagnosed according to DSM-III-R and DSM-IV criteria. Psychiatric signs and symptoms were assessed by physicians using a structured interview. Cognitive functioning was assessed with the Mini-Mental State. RESULTS At the initial screening, the patients later diagnosed as depressed had a greater number of depressive symptoms, such as dysphoria and appetite disturbance, and their symptoms were also more severe than those of the nondepressed subjects. Moreover, the depressed subjects suffered from a more severe lack of interest and psychomotor disturbance and had lower Mini-Mental State scores. CONCLUSIONS There are preclinical markers for individuals who will become depressed after a 3-year interval. Major depression may have a more chronic nature in very old age, in contrast to the relatively short clinical onset of depression seen in younger adults. The authors conclude that standard diagnostic instruments such as DSM-IV may have to take this lengthy course of impairment into consideration when dealing with very old adults.
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Affiliation(s)
- A K Berger
- Stockholm Gerontology Research Center and the Department of Clinical Neuroscience and Family Medicine, Karolinska Institute, Stockholm, Sweden.
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Berger AK, Edris DW, Breall JA, Oetgen WJ, Marciniak TA, Molinari GF. Resource use and quality of care for Medicare patients with acute myocardial infarction in Maryland and the District of Columbia: analysis of data from the Cooperative Cardiovascular Project. Am Heart J 1998; 135:349-56. [PMID: 9489987 DOI: 10.1016/s0002-8703(98)70104-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This study sought to evaluate the quality of care rendered to Medicare beneficiaries with acute myocardial infarction by establishing the use patterns of well-proven therapies in this population. We analyzed the quality of care rendered to 4300 Medicare beneficiaries seen at Maryland and District of Columbia hospitals with retrospectively confirmed acute myocardial infarction by evaluating the use of proven therapies. The proportion of patients ideal for therapies ranged from 10% for reperfusion to 100% for smoking cessation counseling. For ideal patients the following therapies were implemented: aspirin (87%), reperfusion therapy (64%), beta-blockers on discharge (60%), and smoking cessation counseling (41%). A substantial proportion of Medicare patients with acute myocardial infarction has one or more relative or absolute contraindications to standard regimens and therefore are not ideal therapeutic candidates. In the group of ideal patients, those with no therapeutic contraindications, a significant proportion do not receive these treatments.
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Affiliation(s)
- A K Berger
- Institute for Cardiovascular Sciences, Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA
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