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Osowicki J, Hamilton F, Lee TC, Marks M, McCreary EK, McDonald EG, Ryder JH, Tong SYC. Which trial do we need? Empiric Glycopeptides plus clindamycin versus Oxazolidinones for suspected toxic shock and necrotizing soft tissue infections. Clin Microbiol Infect 2024; 30:570-573. [PMID: 38336230 DOI: 10.1016/j.cmi.2024.02.001] [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: 12/18/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK; Infection Sciences, North Bristol NHS Trust, Bristol, UK
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Hospital for Tropical Diseases, University College London Hospital, London, UK; Division of Infection & Immunity, University College London, London, UK
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathan H Ryder
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Bortolussi-Courval É, Podymow T, Battistella M, Trinh E, Mavrakanas TA, McCarthy L, Moryousef J, Hanula R, Huon JF, Suri R, Lee TC, McDonald EG. Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study. Kidney Med 2024; 6:100810. [PMID: 38628463 PMCID: PMC11019279 DOI: 10.1016/j.xkme.2024.100810] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Rationale & Objective Patients treated with dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (eg, falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medication reviews, it can be complex and time-consuming. Whether clinical decision support improves the process and increases deprescribing for patients treated with dialysis is unknown. This study aimed to test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients treated with dialysis. Study Design Prospective controlled quality improvement study with a contemporaneous control. Setting & Participants Patients prescribed ≥5 medications in 2 outpatient dialysis units in Montréal, Canada. Exposures Patient health data from the electronic medical record were input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists in the intervention unit additionally received deprescribing reports, and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. In the control unit, patients received usual care alone. Analytical Approach The proportion of patients with ≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the effect of using MedSafer. The absolute risk difference with 95% CI and number needed to treat were calculated. Outcomes The primary outcome was the proportion of patients with one or more PIMs deprescribed. Secondary outcomes include the reduction in the mean number of prescribed drugs and PIMs from baseline. Results In total, 195 patients were included (127, control unit; 68, intervention unit); the mean age was 64.8 ± 15.9 (SD), and 36.9% were women. The proportion of patients with ≥1 PIMs deprescribed in the control unit was 3.1% (4/127) vs 39.7% (27/68) in the intervention unit (absolute risk difference, 36.6%; 95% CI, 24.5%-48.6%; P < 0.0001; number needed to treat = 3). Limitations This was a single-center nonrandomized study with a type 1 error risk. Deprescribing durability was not assessed, and the study was not powered to reduce adverse drug events. Conclusions Deprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed.
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Affiliation(s)
- Émilie Bortolussi-Courval
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Tiina Podymow
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marisa Battistella
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Emilie Trinh
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thomas A. Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lisa McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Moryousef
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Jean-François Huon
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Pharmacy, Nantes University Health Centre, Nantes University, Nantes, France
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Disease, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G. McDonald
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Prosty C, Katergi K, Sorin M, Rjeily MB, Butler-Laporte G, McDonald EG, Lee TC. Comparative efficacy and safety of Pneumocystis jirovecii pneumonia prophylaxis regimens for people living with HIV: a systematic review and network meta-analysis of randomized controlled trials. Clin Microbiol Infect 2024:S1198-743X(24)00168-X. [PMID: 38583518 DOI: 10.1016/j.cmi.2024.03.037] [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] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/18/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection among people living with HIV (PWH), particularly among new and untreated cases. Several regimens are available for the prophylaxis of PCP, including trimethoprim-sulfamethoxazole (TMP-SMX), dapsone-based regimens (DBRs), aerosolized pentamidine (AP), and atovaquone. OBJECTIVES To compare the efficacy and safety of PCP prophylaxis regimens in PWH by network meta-analysis. METHODS DATA SOURCES: Embase, MEDLINE, and CENTRAL from inception to June 21, 2023. STUDY ELIGIBILITY CRITERIA Comparative randomized controlled trials (RCTs). PARTICIPANTS PWH. INTERVENTIONS Regimens for PCP prophylaxis either compared head-to-head or versus no treatment/placebo. ASSESSMENT OF RISK OF BIAS Cochrane risk-of-bias tool for RCTs 2. METHODS OF DATA SYNTHESIS Title or abstract and full-text screening and data extraction were performed in duplicate by two independent reviewers. Data on PCP incidence, all-cause mortality, and discontinuation due to toxicity were pooled and ranked by network meta-analysis. Subgroup analyses of primary versus secondary prophylaxis, by year, and by dosage were performed. RESULTS A total of 26 RCTs, comprising 55 treatment arms involving 7516 PWH were included. For the prevention of PCP, TMP-SMX was ranked the most favourable agent and was superior to DBRs (risk ratio [RR] = 0.54; 95% CI, 0.36-0.83) and AP (RR = 0.53; 95% CI, 0.36-0.77). TMP-SMX was also the only agent with a mortality benefit compared with no treatment/placebo (RR = 0.79; 95% CI, 0.64-0.98). However, TMP-SMX was also ranked as the most toxic agent with a greater risk of discontinuation than DBRs (RR = 1.25; 95% CI, 1.01-1.54) and AP (7.20; 95% CI, 5.37-9.66). No significant differences in PCP prevention or mortality were detected among the other regimens. The findings remained consistent within subgroups. CONCLUSIONS TMP-SMX is the most effective agent for PCP prophylaxis in PWH and the only agent to confer a mortality benefit; consequently, it should continue to be recommended as the first-line agent. Further studies are necessary to determine the optimal dosing of TMP-SMX to maximize efficacy and minimize toxicity.
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Affiliation(s)
- Connor Prosty
- Faculty of Medicine, McGill University, Montréal, QC, Canada.
| | - Khaled Katergi
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Mark Sorin
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | | | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, QC, Montréal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada; Department of Medicine, Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, QC, Montréal, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada; Department of Medicine, Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada
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McDonald EG, Afshar A, Assiri B, Boyles T, Hsu JM, Khuong N, Prosty C, So M, Sohani ZN, Butler-Laporte G, Lee TC. Pneumocystis jirovecii pneumonia in people living with HIV: a review. Clin Microbiol Rev 2024; 37:e0010122. [PMID: 38235979 PMCID: PMC10938896 DOI: 10.1128/cmr.00101-22] [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] [Indexed: 01/19/2024] Open
Abstract
Pneumocystis jirovecii is a ubiquitous opportunistic fungus that can cause life-threatening pneumonia. People with HIV (PWH) who have low CD4 counts are one of the populations at the greatest risk of Pneumocystis jirovecii pneumonia (PCP). While guidelines have approached the diagnosis, prophylaxis, and management of PCP, the numerous studies of PCP in PWH are dominated by the 1980s and 1990s. As such, most studies have included younger male populations, despite PCP affecting both sexes and a broad age range. Many studies have been small and observational in nature, with an overall lack of randomized controlled trials. In many jurisdictions, and especially in low- and middle-income countries, the diagnosis can be challenging due to lack of access to advanced and/or invasive diagnostics. Worldwide, most patients will be treated with 21 days of high-dose trimethoprim sulfamethoxazole, although both the dose and the duration are primarily based on historical practice. Whether treatment with a lower dose is as effective and less toxic is gaining interest based on observational studies. Similarly, a 21-day tapering regimen of prednisone is used for patients with more severe disease, yet other doses, other steroids, or shorter durations of treatment with corticosteroids have not been evaluated. Now with the widespread availability of antiretroviral therapy, improved and less invasive PCP diagnostic techniques, and interest in novel treatment strategies, this review consolidates the scientific body of literature on the diagnosis and management of PCP in PWH, as well as identifies areas in need of more study and thoughtfully designed clinical trials.
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Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Avideh Afshar
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Bander Assiri
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tom Boyles
- Right to Care, NPC, Centurion, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jimmy M. Hsu
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University of Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Zahra N. Sohani
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Prosty C, Katergi K, Nguyen A, Luo OD, Sorin M, Cherniak V, Sebag M, Demir K, McDonald EG, Lee TC, Cheng MP. Risk of infectious adverse events of venetoclax therapy for hematologic malignancies: a systematic review and meta-analysis of RCTs. Blood Adv 2024; 8:857-866. [PMID: 38154071 PMCID: PMC10875332 DOI: 10.1182/bloodadvances.2023011964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023] Open
Abstract
ABSTRACT Venetoclax is a small molecule inhibitor of BCL-2 used in the treatment of acute myelogenous leukemia (AML) and chronic lymphocytic leukemia (CLL). Recent postmarketing studies of ibrutinib, another small molecule inhibitor, suggested that these agents may predispose to opportunistic infections. We sought to systematically review the randomized controlled trial (RCT) evidence of venetoclax to assess whether it predisposes patients to infectious adverse events (IAEs) and neutropenia. We systematically reviewed RCTs comparing venetoclax therapy with active or placebo controls for patients with hematologic malignancies. Data on IAEs and neutropenia were pooled by Bayesian meta-analysis, and we computed the probability of any increased risk (P[risk ratio (RR) > 1]) of IAEs or neutropenic complications. Seven RCTs were included, comprising 2067 patients. In CLL (n = 1032), there was a low probability of increased risk of high-grade (P[RR > 1] = 71.2%) and fatal IAEs (P[RR > 1] = 64.5%) and high-grade neutropenia (P[RR > 1] = 63.4%). There were insufficient data to perform a meta-analysis of IAEs in AML; however, 1 trial suggested an increased risk of IAEs with venetoclax. Furthermore, in AML (n = 642), venetoclax was associated with a high probability of increased risk of high-grade neutropenia (P[RR > 1] = 94.6%) and febrile neutropenia (P[RR > 1] = 90.6%). Our results suggest that venetoclax has a low probability of increased risk of IAEs or neutropenia in CLL. By contrast, there is likely increased risk of high-grade neutropenia and febrile neutropenia in AML. Importantly, our analyses did not identify any specific IAEs that would benefit from routine antimicrobial prophylaxis or pre-emptive testing.
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Affiliation(s)
- Connor Prosty
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Khaled Katergi
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Alex Nguyen
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Owen Dan Luo
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Mark Sorin
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Vladimir Cherniak
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Michael Sebag
- Division of Hematology, Department of Medicine, McGill University, Montréal, QC, Canada
| | - Koray Demir
- Division of Infectious Diseases, Department of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Matthew P. Cheng
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
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Prosty C, Hanula R, Katergi K, Longtin Y, McDonald EG, Lee TC. Clinical Outcomes and Management of NAAT-Positive/Toxin-Negative Clostridioides difficile Infection: A Systematic Review and Meta-Analysis. Clin Infect Dis 2024; 78:430-438. [PMID: 37648251 DOI: 10.1093/cid/ciad523] [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: 05/23/2023] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Standalone nucleic acid amplification tests (NAATs) are frequently used to diagnose Clostridioides difficile infections (CDI), although they may be unable to distinguish colonization from disease. A 2-stage algorithm pairing NAATs with toxin immunoassays (Toxin) may improve specificity. We evaluated clinical outcomes of patients who were NAAT+/Toxin+ versus NAAT+/Toxin- and treated versus untreated NAAT+/Toxin- cases through systematic review and meta-analysis. METHODS We searched EMBASE and MEDLINE from inception to April 1, 2023 for articles comparing CDI outcomes among symptomatic patients tested by NAAT and Toxin tests. The risk differences (RD) of all-cause mortality and CDI recurrence were computed by random effects meta-analysis between patients who were NAAT+/Toxin+ and NAAT+/Toxin-, as well as between patients who were NAAT+/Toxin- and treated or untreated. RESULTS Twenty-six observational studies comprising 12 737 patients were included. The 30-day all-cause mortality was not significantly different between those who were NAAT+/Toxin+ (8.4%) and NAAT+/Toxin- (6.7%) (RD = 0.41%, 95% confidence interval [CI] = -.67, 1.49). Recurrence at 60 days was significantly higher among patients who were NAAT+/Toxin+ (19.8%) versus NAAT+/Toxin- (11.0%) (RD = 7.65%, 95% CI = 4.60, 10.71). Among treated compared to untreated NAAT+/Toxin- cases, the all-cause 30-day mortalities were 5.0% and 12.7%, respectively (RD = -7.45%, 95% CI = -12.29, -2.60), but 60-day recurrence was not significantly different (11.6% vs 7.0%, respectively; RD = 5.25%, 95% CI -1.71, 12.22). CONCLUSIONS Treatment of patients who were NAAT+/Toxin- was associated with reduced all-cause mortality but not recurrence. Although subject to the inherent limitations of observational studies, these results suggest that some patients who are NAAT+/Toxin- may benefit from treatment.
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Affiliation(s)
- Connor Prosty
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada
| | - Khaled Katergi
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Yves Longtin
- Division of Infectious Diseases, Department of Medicine, Jewish General Hospital Sir Mortimer B. Davis, Montréal, QC, Canada
| | - Emily G McDonald
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, QC, Montréal, Canada
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [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] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Rouette J, McDonald EG, Schuster T, Matok I, Brophy JM, Azoulay L. Thiazide Diuretics and Risk of Colorectal Cancer: A Population-Based Cohort Study. Am J Epidemiol 2024; 193:47-57. [PMID: 37579305 DOI: 10.1093/aje/kwad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 05/05/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023] Open
Abstract
Evidence from clinical trials and observational studies on the association between thiazide diuretics and colorectal cancer risk is conflicting. We aimed to determine whether thiazide diuretics are associated with an increased colorectal cancer risk compared with dihydropyridine calcium channel blockers (dCCBs). A population-based, new-user cohort was assembled using the UK Clinical Practice Research Datalink. Between 1990-2018, we compared thiazide diuretic initiators with dCCB initiators and estimated hazard ratios (HR) with 95% confidence intervals (CIs) of colorectal cancer using Cox proportional hazard models. Models were weighted using standardized morbidity ratio weights generated from calendar time-specific propensity scores. The cohort included 377,760 thiazide diuretic initiators and 364,300 dCCB initiators, generating 3,619,883 person-years of follow-up. Compared with dCCBs, thiazide diuretics were not associated with colorectal cancer (weighted HR = 0.97, 95% CI: 0.90, 1.04). Secondary analyses yielded similar results, although an increased risk was observed among patients with inflammatory bowel disease (weighted HR = 2.45, 95% CI: 1.13, 5.35) and potentially polyps (weighted HR = 1.46, 95% CI: 0.93, 2.30). Compared with dCCBs, thiazide diuretics were not associated with an overall increased colorectal cancer risk. While these findings provide some reassurance, research is needed to corroborate the elevated risks observed among patients with inflammatory bowel disease and history of polyps.
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Ong SWX, Patel D, Reinblatt S, Tong SYC, Lee TC, McDonald EG, Daneman N. Choosing the right outcomes in infectious diseases clinical research-putting patients front and centre. Clin Microbiol Infect 2024; 30:10-14. [PMID: 37918512 DOI: 10.1016/j.cmi.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Sean W X Ong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Devangi Patel
- Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada
| | | | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada; Division of Infectious Diseases, McGill University Health Centre, Montréal, QC, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada; Division of General Internal Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Nick Daneman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Hanula R, Bortolussi-Courval É, Mendel A, Ward BJ, Lee TC, McDonald EG. Evaluation of Oseltamivir Used to Prevent Hospitalization in Outpatients With Influenza: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024; 184:18-27. [PMID: 37306992 PMCID: PMC10262060 DOI: 10.1001/jamainternmed.2023.0699] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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] [Received: 07/15/2022] [Accepted: 01/06/2023] [Indexed: 06/13/2023]
Abstract
Importance Despite widespread use, summary evidence from prior meta-analyses has contradictory conclusions regarding whether oseltamivir decreases the risk of hospitalization when given to outpatients. Several large investigator-initiated randomized clinical trials have not yet been meta-analyzed. Objective To assess the efficacy and safety of oseltamivir in preventing hospitalization among influenza-infected adult and adolescent outpatients. Data Sources PubMed, Ovid MEDLINE, Embase, Europe PubMed Central, Web of Science, Cochrane Central, ClinicalTrials.gov, and WHO International Clinical Trials Registry were searched from inception to January 4, 2022. Study Selection Included studies were randomized clinical trials comparing oseltamivir vs placebo or nonactive controls in outpatients with confirmed influenza infection. Data Extraction and Synthesis In this systematic review and meta-analysis, Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Two independent reviewers (R.H. and É.B.C.) extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 2.0. Each effect size was pooled using a restricted maximum likelihood random effects model. The quality of evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Main Outcomes and Measures Hospitalization was pooled as risk ratio (RR) and risk difference (RD) estimates with 95% CIs. Results Of 2352 studies identified, 15 were included. The intention-to-treat infected (ITTi) population was comprised of 6166 individuals with 54.7% prescribed oseltamivir. Across study populations, 53.9% (5610 of 10 471) were female and the mean age was 45.3 (14.5) years. Overall, oseltamivir was not associated with reduced risk of hospitalization within the ITTi population (RR, 0.79; 95% CI, 0.48 to 1.29; RD, -0.17%; 95% CI, -0.23% to 0.48%). Oseltamivir was also not associated with reduced hospitalization in older populations (mean age ≥65 years: RR, 1.01; 95% CI, 0.21 to 4.90) or in patients considered at greater risk of hospitalization (RR, 0.65; 0.33 to 1.28). Within the safety population, oseltamivir was associated with increased nausea (RR, 1.43; 95% CI, 1.13 to 1.82) and vomiting (RR, 1.83; 95% CI, 1.28 to 2.63) but not serious adverse events (RR, 0.71; 95% CI, 0.46 to1.08). Conclusions and Relevance In this systematic review and meta-analysis among influenza-infected outpatients, oseltamivir was not associated with a reduced risk of hospitalization but was associated with increased gastrointestinal adverse events. To justify continued use for this purpose, an adequately powered trial in a suitably high-risk population is justified.
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Affiliation(s)
- Ryan Hanula
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Émilie Bortolussi-Courval
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Todd C Lee
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G McDonald
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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11
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McDonald EG, Hanula R, Lee TC. Oseltamivir May or May Not Reduce Hospitalizations-Reply. JAMA Intern Med 2024; 184:117-118. [PMID: 37983041 DOI: 10.1001/jamainternmed.2023.5769] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ryan Hanula
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada
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12
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Alexander GC, Budnitz D, Hughes C, Maas R, Mair A, McDonald EG, Meid AD, Payne R, Seidling HM, Shakir S, Suissa S, Tannenbaum C, Schneeweiss S, Dreischulte T. Proceedings of the International Ambulatory Drug Safety Symposium: Munich, Germany, June 2023. Drug Saf 2024; 47:103-111. [PMID: 37917316 DOI: 10.1007/s40264-023-01362-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Affiliation(s)
- G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6035, Baltimore, MD, 21205, USA.
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany.
| | - Daniel Budnitz
- Kenvue, Fort Washington, PA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
- United States Public Health Service (Retired), Atlanta, GA, USA
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Renke Maas
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, UK
| | - Emily G McDonald
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, QC, Canada
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rupert Payne
- Exeter Collaboration for Academic Primary Care (APEx), Exeter Medical School, University of Exeter, Exeter, UK
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Saad Shakir
- Drug Safety Research Unit, University of Portsmouth, Southampton, UK
| | - Samy Suissa
- Department of Epidemiology and Biostatistics, and Department of Medicine, McGill University, Montreal, QC, Canada
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | | | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
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Thompson W, Reeve E, McDonald EG, Farrell B, Scott S, Steinman MA, Morin L, Lundby C. Ten deprescribing articles you should know about: A guide for newcomers to the field. Basic Clin Pharmacol Toxicol 2023; 133:661-664. [PMID: 37142559 PMCID: PMC10831497 DOI: 10.1111/bcpt.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, SA, Australia
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Barbara Farrell
- Bruyere Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- University of Waterloo School of Pharmacy, Waterloo, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, United Kingdom
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, California, USA
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Inserm CIC 1431, CHU Besançon, Besançon, France
- Inserm U1018, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
| | - Carina Lundby
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
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14
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Weir DL, Ma X, McCarthy L, Tang T, Lapointe-Shaw L, Wodchis WP, Fernandes O, McDonald EG. Medication clusters at hospital discharge and risk of adverse drug events at 30 days postdischarge: A population-based cohort study of older adults. Br J Clin Pharmacol 2023; 89:3715-3752. [PMID: 37565499 DOI: 10.1111/bcp.15872] [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: 04/05/2023] [Revised: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023] Open
Abstract
AIMS Certain combinations of medications can be harmful and may lead to serious adverse drug events (ADEs). Identifying potentially problematic medication clusters could help guide prescribing and/or deprescribing decisions in hospital. The aim of this study is to characterize medication prescribing patterns at hospital discharge and determine which medication clusters were associated with an increased risk of ADEs in the 30-day posthospital discharge. METHODS All residents of the province of Ontario in Canada aged 66 years or older admitted to hospital between March 2016 and February 2017 were included. Identification of medication clusters prescribed at hospital discharge was conducted using latent class analysis. Cluster identification and categorization were based on medications dispensed up to 30-day posthospitalization. Multivariable logistic regression was used to assess the potential association between membership to a particular medication cluster and ADEs postdischarge, while also evaluating other patient characteristics. RESULTS In total, 188 354 patients were included in the study cohort. Median age (interquartile range) was 77 (71-84) years, and patients had a median (IQR) (interquartile range [IQR]) of 9 (6-13) medications dispensed prior to admission. Within the study population, 6 separate clusters of dispensing patterns were identified: cardiovascular (14%), respiratory (26%), complex care needs (12%), cardiovascular and metabolic (15%), infection (10%), and surgical (24%). Overall, 12 680 (7%) patients had an ADE in the 30 days following discharge. After considering other patient characteristics, those belonging to the respiratory cluster had the highest risk of ADEs (adjusted odds ratio: 1.12, 95% confidence interval: 1.08-1.17) compared with all the other clusters, while those in the complex care needs cluster had the lowest risk (adjusted odds ratio: 0.82, 95% confidence interval: 0.77-0.87). CONCLUSION This study suggests that ADEs post hospital discharge can be linked with identifiable medication clusters. This information may help clinicians and researchers better understand patient populations that are more or less likely to benefit from peri-hospital discharge interventions aimed at reducing ADEs.
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Affiliation(s)
- Daniala L Weir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Xiaomeng Ma
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Health System Performance Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lisa McCarthy
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
- Department of Pharmacy, Trillium Health Partners, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
- Department of Pharmacy, Trillium Health Partners, Toronto, Ontario, Canada
- Department of Internal Medicine, Trillium Health Partners, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Health System Performance Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
| | | | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
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15
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Roy AS, Hagh-Doust H, Abdul Azim A, Caceres J, Denholm JT, Dong MQ(D, King M, Yen CF, Lee TC, McDonald EG. Multidisciplinary Teams for the Management of Infective Endocarditis: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2023; 10:ofad444. [PMID: 37674631 PMCID: PMC10478154 DOI: 10.1093/ofid/ofad444] [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] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023] Open
Abstract
Background The management of infective endocarditis (IE) is complex owing to a high burden of morbidity and mortality. Recent guidelines recommend dedicated multidisciplinary teams (MDTs) for the management of IE. The aim of this systematic review and meta-analysis was to evaluate and summarize the effect of MDT management on patient outcomes. Methods A systematic review was performed and, where feasible, results were meta-analyzed; otherwise, results were summarized narratively. Data extraction and quality assessment were performed in duplicate. Restricted maximum likelihood random effects models were used to calculate unadjusted risk ratios and 95% CIs. Results Screening of 2343 studies based on title and abstract yielded 60 full-text reviews; 18 studies were summarized narratively, of which 15 were included in a meta-analysis of short-term mortality. Meta-analysis resulted in a risk ratio of 0.61 (95% CI, .47-.78; I2 = 62%) for mortality in favor of a dedicated MDT as compared with usual care. Length of stay was variable, with 55% (10/18) of studies reporting an increased length of stay. Most studies (16/18, 88.9%) reported a decreased time to surgery and an increased rate of surgery (13/18, 73%). No studies reported on patient-reported outcomes. Conclusions This is the first systematic review and meta-analysis to assess the impact of MDT management on IE. The sum of evidence demonstrated a significant association between MDTs and improved short-term mortality. Further research is needed to evaluate benefits of virtual MDT care, cost-effectiveness, and the impact on patient-reported outcomes and long-term mortality.
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Affiliation(s)
- Anne-Sophie Roy
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Hamila Hagh-Doust
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Ahmed Abdul Azim
- Division of Infectious Diseases, Allergy and Immunology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Juan Caceres
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Justin T Denholm
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Australia
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Mei Qin (Denise) Dong
- Antimicrobial Stewardship Pharmacy, New York Health and Hospitals, Bellevue Hospital, New York City, New York, USA
| | - Madeline King
- Outpatient Antimicrobial Stewardship Clinical Pharmacy, Cooper University Healthcare, Camden, New Jersey, USA
| | - Christina F Yen
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada
- Division of Infectious Diseases, McGill University Health Centre, Montreal, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Canada
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16
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Reiersen AM, Mattar C, Bender Ignacio RA, Boulware DR, Lee TC, Hess R, Lankowski AJ, McDonald EG, Miller JP, Powderly WG, Pullen MF, Rado JT, Rich MW, Schiffer JT, Schweiger J, Spivak AM, Stevens A, Vigod SN, Agarwal P, Yang L, Yingling M, Gettinger TR, Zorumski CF, Lenze EJ. The STOP COVID 2 Study: Fluvoxamine vs Placebo for Outpatients With Symptomatic COVID-19, a Fully Remote Randomized Controlled Trial. Open Forum Infect Dis 2023; 10:ofad419. [PMID: 37622035 PMCID: PMC10445518 DOI: 10.1093/ofid/ofad419] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023] Open
Abstract
Background Prior randomized clinical trials have reported benefit of fluvoxamine ≥200 mg/d vs placebo for patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods This randomized, double-blind, placebo-controlled, fully remote multisite clinical trial evaluated whether fluvoxamine prevents clinical deterioration in higher-risk outpatients with acute coronavirus disease 2019 (COVID-19). Between December 2020 and May 2021, nonhospitalized US and Canadian participants with confirmed symptomatic infection received fluvoxamine (50 mg on day 1, 100 mg twice daily thereafter) or placebo for 15 days. The primary modified intent-to-treat (mITT) population included participants who started the intervention within 7 days of symptom onset with a baseline oxygen saturation ≥92%. The primary outcome was clinical deterioration within 15 days of randomization, defined as having both (1) shortness of breath (severity ≥4 on a 0-10 scale or requiring hospitalization) and (2) oxygen saturation <92% on room air or need for supplemental oxygen. Results A total of 547 participants were randomized and met mITT criteria (n = 272 fluvoxamine, n = 275 placebo). The Data Safety Monitoring Board recommended stopping early for futility related to lower-than-predicted event rates and declining accrual concurrent with vaccine availability in the United States and Canada. Clinical deterioration occurred in 13 (4.8%) participants in the fluvoxamine group and 15 (5.5%) participants in the placebo group (absolute difference at day 15, 0.68%; 95% CI, -3.0% to 4.4%; log-rank P = .91). Conclusions This trial did not find fluvoxamine efficacious in preventing clinical deterioration in unvaccinated outpatients with symptomatic COVID-19. It was stopped early and underpowered due to low primary outcome rates. Clinical Trials Registration ClinicalTrials.gov Identifier: NCT04668950.
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Affiliation(s)
- Angela M Reiersen
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caline Mattar
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rachel A Bender Ignacio
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Allergy & Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Department of Medicine, Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Rachel Hess
- Division of Health System Innovation and Research, University of Utah, Salt Lake City, Utah, USA
- Division of General Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alexander J Lankowski
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Emily G McDonald
- Department of Medicine, Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - J Philip Miller
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William G Powderly
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey T Rado
- Departments of Psychiatry & Behavioral Sciences and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael W Rich
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua T Schiffer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Allergy & Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Julie Schweiger
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Adam M Spivak
- Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
| | - Angela Stevens
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Simone N Vigod
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto and Women's College Hospital, Toronto, Ontario, Canada
| | - Payal Agarwal
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto and Women's College Hospital, Toronto, Ontario, Canada
| | - Lei Yang
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael Yingling
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Torie R Gettinger
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Wu PE, Lee TC, McDonald EG. What Should I Know About Medication Deprescribing? JAMA Intern Med 2023; 183:891. [PMID: 37273220 DOI: 10.1001/jamainternmed.2023.2099] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/06/2023]
Abstract
This JAMA Internal Medicine Patient Page describes the process of slowly and carefully cutting down on unnecessary medications with the guidance of a health care professional.
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Affiliation(s)
- Peter E Wu
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, Quebec, Canada
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18
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McDonald EG, Aggrey G, Tarik Aslan A, Casias M, Cortes-Penfield N, Dong MQD, Egbert S, Footer B, Isler B, King M, Maximos M, Wuerz TC, Azim AA, Alza-Arcila J, Bai AD, Blyth M, Boyles T, Caceres J, Clark D, Davar K, Denholm JT, Forrest G, Ghanem B, Hagel S, Hanretty A, Hamilton F, Jent P, Kang M, Kludjian G, Lahey T, Lapin J, Lee R, Li T, Mehta D, Moore J, Mowrer C, Ouellet G, Reece R, Ryder JH, Sanctuaire A, Sanders JM, Stoner BJ, So JM, Tessier JF, Tirupathi R, Tong SYC, Wald-Dickler N, Yassin A, Yen C, Spellberg B, Lee TC. Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open 2023; 6:e2326366. [PMID: 37523190 DOI: 10.1001/jamanetworkopen.2023.26366] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 08/01/2023] Open
Abstract
Importance Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence. Objective To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength. Evidence Review This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches. Findings A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions. Conclusions and Relevance In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Abdullah Tarik Aslan
- The University of Queensland, Faculty of Medicine, Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Michael Casias
- Jersey Shore University Medical Center, Neptune, New Jersey
| | | | | | - Susan Egbert
- Department of Chemistry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brent Footer
- Providence Portland Medical Center, Portland, Oregon
| | - Burcu Isler
- University of Queensland, Centre for Clinical Research, Brisbane, Queensland, Australia
| | | | - Mira Maximos
- Women's College Hospital, Toronto, Ontario, Canada
| | - Terence C Wuerz
- Departments of Internal Medicine & Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmed Abdul Azim
- Division of Infectious Diseases, Allergy and Immunology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Tom Boyles
- Right to Care, NPC, Centurion, South Africa and London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Juan Caceres
- Division of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Devin Clark
- Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Kusha Davar
- Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Justin T Denholm
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | | | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | | | - Fergus Hamilton
- Infection Science, North Bristol NHS Trust, Bristol, United Kingdom
| | - Philipp Jent
- Department of Infectious Diseases, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Minji Kang
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern, Dallas
| | | | - Tim Lahey
- University of Vermont Medical Center, Burlington
| | | | | | - Timothy Li
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Dhara Mehta
- Bellevue Hospital Center, New York, New York
| | | | - Clayton Mowrer
- University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha
| | | | - Rebecca Reece
- Section of Infectious Diseases, West Virginia University, Morgantown
| | - Jonathan H Ryder
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
| | - Alexandre Sanctuaire
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, Canada
| | | | | | - Jessica M So
- Los Angeles County and University of Southern California Medical Center, Los Angeles
| | | | | | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Noah Wald-Dickler
- Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Arsheena Yassin
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Christina Yen
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern, Dallas
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Todd C Lee
- Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada
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19
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Turner JP, Gagnon CL, Khuong NB, McDonald EG, Tannenbaum C. The impact of educational whiteboard videos on healthcare providers' self‐efficacy to deprescribe. J Am Geriatr Soc 2023; 71:E15-E18. [PMID: 36971456 DOI: 10.1111/jgs.18335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Justin P Turner
- Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Camille L Gagnon
- Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada
| | - Ninh B Khuong
- Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Cara Tannenbaum
- Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada
- Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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20
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Yanofsky RP, Abrahami D, Pradhan R, Yin H, McDonald EG, Bitton A, Azoulay L. A66 PROTON PUMP INHIBITORS AND THE RISK OF INFLAMMATORY BOWEL DISEASE: A REAL WORLD POPULATION-BASED COHORT STUDY. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991348 DOI: 10.1093/jcag/gwac036.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are acid suppressant drugs indicated in highly prevalent conditions such as gastroesophageal reflux disease and peptic ulcer disease. A recent observational study reported an increased risk of inflammatory bowel disease (IBD) with the use of PPIs. However, this association may have been driven by certain methodological shortcomings, such as failure to properly account for protopathic bias, a conclusion-altering bias. Purpose To determine whether the use of PPIs compared with the use of H2RAs is associated with an increased risk of IBD. Method Using the longitudinal primary care records from the United Kingdom Clinical Practice Research Datalink database, we identified 1,498,416 initiators of PPIs and 322,474 initiators of H2RAs from January 1, 1990, through December 31, 2018, with follow-up until December 31, 2019. Standardized morbidity ratio weighted Cox proportional hazards models were used to estimate marginal hazard ratios (HRs) and 95% confidence intervals (CIs). Patients were analyzed according to the timing of the IBD events after treatment initiation (early versus late). In the early-event analysis, IBD events were assessed within the first two years of treatment initiation, an analysis subject to potential protopathic bias. In the late-event analysis, all exposures were lagged by two years to account for latency and minimize protopathic bias. Result(s) In the early-event analysis, the use of PPIs was associated with an increased risk of IBD within the first two years of treatment initiation, compared with H2RAs (HR: 1.39, 95% CI: 1.14-1.69). In contrast, the use of PPIs was not associated with an increased risk of IBD in the late-event analysis (HR: 1.05, 95% CI: 0.90 to 1.22). The results remained consistent in several sensitivity analyses. Image ![]()
Conclusion(s) Compared with H2RAs, PPIs were not associated with an increased risk of IBD, after accounting for protopathic bias. Please acknowledge all funding agencies by checking the applicable boxes below CIHR Disclosure of Interest R. Yanofsky: None Declared, D. Abrahami Employee of: pfizer, R. Pradhan: None Declared, H. Yin: None Declared, E. McDonald: None Declared, A. Bitton Consultant of: Member of Advisory Boards for Abbie, Pfizer, Takeda, Jansen, and Merck, Speakers bureau of: Has received speaker fees for Abbie, Jansen, Takeda, and Pfizer, L. Azoulay Consultant of: Has received consults fees from Jansen, Pfizer, and Roche, Speakers bureau of: Has received speaker fees from Jansen, Pfizer, and Roche
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Affiliation(s)
- R P Yanofsky
- Department of Gastroenterology & Hepatology, University of Toronto, Toronto, Canada
| | - D Abrahami
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard University, Boston, United States
| | - R Pradhan
- Department of Epidemiology, Biostatistics, and Occupational Health
| | - H Yin
- Department of Epidemiology, Biostatistics, and Occupational Health
| | | | - A Bitton
- Gastroenterology & Hepatology, McGill University, Montreal, Canada
| | - L Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health
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21
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Lee TC, McDonald EG, Tong SYC. PET Scan in S. aureus bacteremia: Peeking Under the Covers. Clin Infect Dis 2023:7069456. [PMID: 36869804 DOI: 10.1093/cid/ciad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Affiliation(s)
- Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
| | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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22
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Mitjà O, Reis G, Boulware DR, Spivak AM, Sarwar A, Johnston C, Webb B, Hill MD, Smith D, Kremsner P, Curran M, Carter D, Alexander J, Corbacho M, Lee TC, Hullsiek KH, McDonald EG, Hess R, Hughes M, Baeten JM, Schwartz I, Metz L, Richer L, Chew KW, Daar E, Wohl D, Dunne M. Hydroxychloroquine for treatment of non-hospitalized adults with COVID-19: A meta-analysis of individual participant data of randomized trials. Clin Transl Sci 2023; 16:524-535. [PMID: 36601684 PMCID: PMC10014689 DOI: 10.1111/cts.13468] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023] Open
Abstract
Hydroxychloroquine (HCQ) was initially promoted as an oral therapy for early treatment of coronavirus disease 2019 (COVID-19). Conventional meta-analyses cannot fully address the heterogeneity of different designs and outcomes of randomized controlled trials (RCTs) assessing the efficacy of HCQ in outpatients with mild COVID-19. We conducted a pooled analysis of individual participant data from RCTs that evaluated the effect of HCQ on hospitalization and viral load reduction in outpatients with confirmed COVID-19. We evaluated the overall treatment group effect by log-likelihood ratio test (-2LL) from a generalized linear mixed model to accommodate correlated longitudinal binary data. The analysis included data from 11 RCTs. The outcome of virological effect, assessed in 1560 participants (N = 795 HCQ, N = 765 control), did not differ significantly between the two treatment groups (-2LL = 7.66; p = 0.18) when adjusting for cohort, duration of symptoms, and comorbidities. The decline in polymerase chain reaction positive tests from day 1 to 7 was 42.0 and 41.6 percentage points in the HCQ and control groups, respectively. Among the 2037 participants evaluable for hospitalization (N = 1058 HCQ, N = 979 control), we found no significant differences in hospitalization rate between participants receiving HCQ and controls (odds ratio 0.995; 95% confidence interval 0.614-1.610; -2LL = 0.0; p = 0.98) when adjusting for cohort, duration of symptoms, and comorbidities. This individual participant data meta-analysis of 11 HCQ trials that evaluated severe acute respiratory syndrome-coronavirus 2 viral clearance and COVID-19 hospitalization did not show a clinical benefit of HCQ. Our meta-analysis provides evidence to support the interruption in the use of HCQ in mild COVID-19 outpatients to reduce progression to severe disease.
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Affiliation(s)
- Oriol Mitjà
- Fight AIDS and Infectious Diseases Foundation, Barcelona, Spain
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Lihir Medical Center-International SOS, Lihir Island, Papua New Guinea
| | - Gilmar Reis
- Research Division, Cardresearch Cardiologia Assistencial e de Pesquisa, Pontifícia Universidade Católica de Minas Gerais, Bello Horizonte, Brazil
- Cytel Inc., Vancouver, British Columbia, Canada
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Ammar Sarwar
- Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Johnston
- Department of Medicine and Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Brandon Webb
- Intermountain Health Care, University of Utah, Salt Lake City, Utah, USA
| | | | - Davey Smith
- Division of Infectious Diseases & Global Public Health, UC San Diego School of Medicine, San Diego, California, USA
| | - Peter Kremsner
- University Hospital of Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon
| | - Marla Curran
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | | | - Jim Alexander
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | - Marc Corbacho
- Fight AIDS and Infectious Diseases Foundation, Barcelona, Spain
| | - Todd C Lee
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katherine Huppler Hullsiek
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emily G McDonald
- Division of General Internal Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Rachel Hess
- University of Utah, Salt Lake City, Utah, USA
| | | | - Jared M Baeten
- Department of Medicine and Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | | | - Luanne Metz
- University of Calgary, Calgary, Alberta, Canada
| | | | - Kara W Chew
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Eric Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - David Wohl
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael Dunne
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
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23
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Akhtar H, Chaudhry SH, Bortolussi-Courval É, Hanula R, Akhtar A, Nauche B, McDonald EG. Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:946-958. [PMID: 36434820 DOI: 10.1111/jgs.18134] [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: 05/05/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging. METHODS We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I2 statistic. Factors associated with an abnormal CT head were summarized qualitatively. RESULTS Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I2 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield. CONCLUSION Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.
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Affiliation(s)
- Haris Akhtar
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Shazia H Chaudhry
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Anas Akhtar
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Bénédicte Nauche
- McGill University Health Centre Medical Libraries, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
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24
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Prosty C, Hanula R, Levin Y, Bogoch II, McDonald EG, Lee TC. Revisiting the Evidence Base for Modern-Day Practice of the Treatment of Toxoplasmic Encephalitis: A Systematic Review and Meta-Analysis. Clin Infect Dis 2023; 76:e1302-e1319. [PMID: 35944134 DOI: 10.1093/cid/ciac645] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 05/20/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Toxoplasmic encephalitis (TE) is an opportunistic infection of people with human immunodeficiency virus (HIV) or other causes of immunosuppression. Guideline-recommended treatments for TE are pyrimethamine and sulfadiazine (P-S) or pyrimethamine and clindamycin (P-C); however, a substantial price increase has limited access to pyrimethamine. Consequently, some centers have transitioned to trimethoprim-sulfamethoxazole (TMP-SMX), an inexpensive alternative treatment. We aimed to review the evidence on the efficacy and safety of pyrimethamine-containing therapies vs TMP-SMX. METHODS We searched for and included randomized controlled trials (RCTs) and observational studies of TE treatments, regardless of HIV status. Data for each therapy were pooled by meta-analysis to assess the proportions of patients who experienced clinical and radiologic responses to treatment, all-cause mortality, and discontinuation due to toxicity. Sensitivity analyses limited to RCTs directly compared therapies. RESULTS We identified 6 RCTs/dose-escalation studies and 26 single-arm/observational studies. Identified studies included only persons with HIV, and most predated modern antiretroviral treatment. Pooled proportions of clinical and radiologic response and mortality were not significantly different between TMP-SMX and pyrimethamine-containing regimens (P > .05). Treatment discontinuation due to toxicity was significantly lower in TMP-SMX (7.3%; 95% confidence interval [CI], 4.7-11.4; I2 = 0.0%) vs P-S (30.5%; 95% CI, 27.1-34.2; I2 = 0.0%; P < .01) or P-C (13.7%; 95% CI, 9.8-18.8; I2 = 32.0%; P = .031). These results were consistent in analyses restricted to RCT data. CONCLUSIONS TMP-SMX appears to be as effective and safer than pyrimethamine-containing regimens for TE. These findings support modern RCTs comparing TMP-SMX to pyrimethamine-based therapies and a revisiting of the guidelines.
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Affiliation(s)
- Connor Prosty
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Yossef Levin
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Isaac I Bogoch
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emily G McDonald
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada.,Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Québec, Montréal, Canada
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25
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McDonald EG, Prosty C, Hanula R, Bortolussi-Courval É, Albuquerque AM, Tong SYC, Hamilton F, Lee TC. Observational versus randomized controlled trials to inform antibiotic treatment durations: a narrative review. Clin Microbiol Infect 2023; 29:165-170. [PMID: 36108947 DOI: 10.1016/j.cmi.2022.09.002] [Citation(s) in RCA: 1] [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: 07/06/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies comparing shorter and longer antibiotic treatment durations are increasingly common. Randomized controlled trials (RCTs) are an ideal methodological approach to study antibiotic treatment durations; however, these trials can be logistically and financially challenging to conduct. OBJECTIVES In this narrative review, we sought to compare the strengths and limitations of observational study data with those of RCT data in evaluating antibiotic treatment durations. We used uncomplicated Gram-negative bacteraemia as an illustrative case example because several published RCTs and observational studies have been conducted in similar patient populations. SOURCES We searched MEDLINE for articles comparing treatment durations for gram-negative bacteremia from inception to June 9th, 2022. We included studies reporting on all-cause mortality and/or relapse at day 28-30. Data comparing short- versus long-course therapy were pooled by Bayesian random effects meta-analyses to assess the odds ratios (OR) of all-cause mortality and relapse at 30 days, stratified by study design. Parameters were summarized with median and 95% highest-density credible intervals (CrI). Posterior probabilities of OR > 1.0 were estimated. Observational studies were further examined to determine if and how they addressed potential sources of bias. CONTENT We identified 1671 unique records and included 10 studies (seven observational and three RCTs). With respect to 30-day mortality, the Bayesian posterior probability that a longer course of therapy was better (i.e. OR >1.0) was 42% in RCTs (OR, 0.94; 95% CrI, 0.51-1.68) and 91% in observational studies (OR, 1.25; 95% CrI, 0.88-1.73). No observational study fully addressed all potential sources of bias. IMPLICATIONS On the basis of our findings, we discuss future directions for antibiotic treatment duration trials, including approaches to limit sources of bias in observation data and novel trial designs.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montréal, Québec, Canada; Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Arthur M Albuquerque
- School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom; Infection Science, North Bristol NHS Trust, Bristol, United Kingdom
| | - Todd C Lee
- Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada; Division of Infectious Diseases, McGill University Health Centre, Montréal, Québec, Canada
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26
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Patel D, Senecal J, Spellberg B, Morris AM, Saxinger L, Footer BW, McDonald EG, Lee TC. Fidaxomicin to prevent recurrent Clostridioides difficile: what will it cost in the USA and Canada? JAC Antimicrob Resist 2023; 5:dlac138. [PMID: 36632358 PMCID: PMC9825808 DOI: 10.1093/jacamr/dlac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/13/2022] [Indexed: 01/09/2023] Open
Abstract
Importance Recent changes in guidelines for managing Clostridioides difficile infections (CDI) have placed fidaxomicin as a first-line treatment. Objective To estimate the net cost of first-line fidaxomicin compared to vancomycin in the American and Canadian healthcare systems and to estimate the price points at which fidaxomicin would become cost saving for the prevention of recurrence. Data sources and study selection We identified randomized, placebo-controlled trials directly comparing fidaxomicin with vancomycin that reported on recurrence. Medication costs were obtained from the Veterans Affairs Federal Supply Schedule (US) and the Quebec drug formulary (Canada). The average cost of a CDI recurrence was established through a systematic review for each country. Data extraction synthesis and outcome measures For efficacy, data on CDI recurrence at day 40 were pooled using a restricted maximal likelihood random effects model. For the cost review, the mean cost across identified studies was adjusted to reflect May 2022 dollars. These were used to estimate the net cost per recurrence prevented with fidaxomicin and the price point below which fidaxomicin would be cost saving. Results The estimated mean system costs of a CDI recurrence were $15 147USD and $8806CAD, respectively. Preventing one recurrence by using first-line fidaxomicin over vancomycin would cost $38 222USD (95%CI $30 577-$57 332) and $13 760CAD (95%CI $11 008-$20 640), respectively. The probability that fidaxomicin was cost saving exceeded 95% if priced below $1140USD or $860CAD, respectively. Conclusions and Relevance An increased drug expenditure on fidaxomicin may not be offset through recurrence prevention unless the fidaxomicin price is negotiated.
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Affiliation(s)
- Devangi Patel
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Julien Senecal
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
| | - Lynora Saxinger
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Canada,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Canada
| | - Todd C Lee
- Corresponding author. E-mail: @DrToddLee, @ASPphysician, @DrEmilyMcD, @BrentFooter, @AntibioticDoc, @BradSpellberg
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27
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Lee TC, Almeida N, Pelletier P, McDonald EG. Comparison of Blood Transfusion Rates Before and After Implementation of a Quality Improvement Initiative for Transfusion Safety and Appropriateness. JAMA Netw Open 2023; 6:e2252253. [PMID: 36689230 PMCID: PMC9871798 DOI: 10.1001/jamanetworkopen.2022.52253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023] Open
Abstract
This quality improvement study compares blood transfusion rates among patients at a single tertiary care hospital before and after the implementation of a transfusion training model completed by incoming resident physicians.
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Affiliation(s)
- Todd C. Lee
- Division of Infectious Diseases, McGill University, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, McGill University Health Center, Montreal, Quebec, Canada
| | - Nisha Almeida
- Health Technology Assessment Unit, McGill University Health Center, Montreal, Quebec, Canada
| | | | - Emily G. McDonald
- Clinical Practice Assessment Unit, McGill University Health Center, Montreal, Quebec, Canada
- Division of General Internal Medicine, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, McGill University, Montreal, Quebec, Canada
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28
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Albuquerque AM, Eckert I, Tramujas L, Butler-Laporte G, McDonald EG, Brophy JM, Lee TC. Effect of tocilizumab, sarilumab, and baricitinib on mortality among patients hospitalized for COVID-19 treated with corticosteroids: a systematic review and meta-analysis. Clin Microbiol Infect 2023; 29:13-21. [PMID: 35863630 PMCID: PMC9293401 DOI: 10.1016/j.cmi.2022.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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: 05/27/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Randomized controlled trials (RCT) established the mortality reduction by tocilizumab (Actemra), baricitinib (Olumiant), and sarilumab (Kevzara) in hospitalized COVID-19 patients. However, uncertainty remains about which treatment performs best in patients receiving corticosteroids. OBJECTIVES To estimate probabilities of noninferiority between baricitinib and sarilumab compared to tocilizumab in patients treated with corticosteroids. DATA SOURCES PubMed, Embase, Cochrane Library, and MedRxiv. STUDY ELIGIBILITY CRITERIA Eligible RCTs assigning hospitalized adults with COVID-19 treated with corticosteroids to tocilizumab or baricitinib or sarilumab versus standard of care or placebo (control). METHODS Reviewers independently abstracted published data and assessed study quality with the Risk of Bias 2 tool. Unpublished data, if required, were requested from authors of included studies. The outcome of interest was all-cause mortality at 28 days. PARTICIPANTS Twenty-seven RCTs with 13 549 patients were included. Overall, the risk of bias was low. Bayesian pairwise meta-analyses were used to aggregate results of each treatment versus control. The average odds ratio for mortality was 0.78 (95% credible interval [CrI]: 0.65, 0.94) for tocilizumab; 0.78 (95% CrI: 0.56, 1.03) for baricitinib; and 0.91 (95% CrI: 0.60, 1.40) for sarilumab. The certainty of evidence (GRADE) ranged from moderate to low. Bayesian meta-regressions with multiple priors were used to estimate probabilities of noninferiority (margin of 13% greater effect by tocilizumab). Compared to tocilizumab, there were ≤94% and 90% probabilities of noninferiority with baricitinib and sarilumab, respectively. RESULTS All but two studies included data with only indirect evidence for the comparison of interest. CONCLUSIONS Among hospitalized COVID-19 treated with corticosteroids, there are high probabilities that both baricitinib and sarilumab are associated with similar mortality reductions in comparison to tocilizumab.
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Affiliation(s)
| | - Igor Eckert
- Department of Nutrition, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | | | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
| | - James M. Brophy
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Division of Cardiology, Department of Medicine, McGill University, Montréal, Canada
| | - Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Corresponding author. Todd C. Lee, Royal Victoria Hospital, 1001 Decarie Blvd Room E5.1820, Montréal, QC H4A3J1, Canada
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Lee TC, McDonald EG. Remdesivir for the treatment of COVID-19: author's response. Clin Microbiol Infect 2023; 29:115-117. [PMID: 36206866 PMCID: PMC9614056 DOI: 10.1016/j.cmi.2022.09.020] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 09/24/2022] [Accepted: 09/25/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Todd C Lee
- Division of Infectious Diseases, McGill University Health Centre, Montréal, Québec, Canada; Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada.
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of General Internal Medicine, McGill University Health Centre, Montréal, Québec, Canada
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Davar K, Clark D, Centor RM, Dominguez F, Ghanem B, Lee R, Lee TC, McDonald EG, Phillips MC, Sendi P, Spellberg B. Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV. Open Forum Infect Dis 2022; 10:ofac706. [PMID: 36694838 PMCID: PMC9853939 DOI: 10.1093/ofid/ofac706] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.
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Affiliation(s)
- Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Devin Clark
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Robert M Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama, Birmingham, Alabama, USA
| | - Fernando Dominguez
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | | | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Brad Spellberg
- Correspondence: Brad Spellberg, MD, Hospital Administration, 2051 Marengo Street, Los Angeles, CA 90033 ()
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Rouette J, McDonald EG, Schuster T, Brophy JM, Azoulay L. Dihydropyridine Calcium Channel Blockers and Risk of Pancreatic Cancer: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e026789. [PMID: 36515246 PMCID: PMC9798809 DOI: 10.1161/jaha.122.026789] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Recent studies have reported that dihydropyridine calcium channel blockers (dCCBs) may increase the risk of pancreatic cancer, but these studies had methodological limitations. We thus aimed to determine whether dCCBs are associated with an increased risk of pancreatic cancer compared with thiazide diuretics, a clinically relevant comparator. Methods and Results We conducted a new user, active comparator, population-based cohort study using the UK Clinical Practice Research Datalink. We identified new users of dCCBs and new users of thiazide diuretics between 1990 and 2018, with follow-up until 2019. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% CIs for pancreatic cancer, comparing dCCBs with thiazide diuretics. Models were weighted using standardized morbidity ratio weights based on calendar time-specific propensity scores. We also conducted secondary analyses by cumulative duration of use, time since initiation, and individual drugs and assessed for the presence of effect modification by age, sex, smoking status, body mass index, history of chronic pancreatitis, and diabetes. The cohort included 344 480 initiators of dCCBs and 357 968 initiators of thiazide diuretics, generating 3 360 745 person-years of follow-up. After a median follow-up of 4.5 years, the weighted incidence rate per 100 000 person-years was 37.2 (95% CI, 34.1-40.4) for dCCBs and 39.4 (95% CI, 36.1-42.9) for thiazide diuretics. Overall, dCCBs were not associated with an increased risk of pancreatic cancer (weighted HR, 0.93; 95% CI, 0.80-1.09). Similar results were observed in secondary analyses. Conclusions In this large, population-based cohort study, dCCBs were not associated with an increased risk of pancreatic cancer compared with thiazide diuretics. These findings provide reassurance regarding the long-term pancreatic cancer safety of these drugs.
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Affiliation(s)
- Julie Rouette
- Centre for Clinical EpidemiologyLady Davis Institute, Jewish General HospitalMontrealCanada,Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of MedicineMcGill University Health CentreMontrealCanada,Division of Experimental MedicineMcGill UniversityMontrealCanada
| | - Tibor Schuster
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada,Department of Family MedicineMcGill UniversityMontrealCanada
| | - James M. Brophy
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada,Division of Clinical EpidemiologyMcGill University Health Centre–Research InstituteMontrealCanada,Department of MedicineMcGill UniversityMontrealCanada
| | - Laurent Azoulay
- Centre for Clinical EpidemiologyLady Davis Institute, Jewish General HospitalMontrealCanada,Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada,Gerald Bronfman Department of OncologyMcGill UniversityMontrealCanada
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Ryder JH, Tong SYC, Gallagher JC, McDonald EG, Thevarajan I, Lee TC, Cortés-Penfield NW. Deconstructing the Dogma: Systematic Literature Review and Meta-analysis of Adjunctive Gentamicin and Rifampin in Staphylococcal Prosthetic Valve Endocarditis. Open Forum Infect Dis 2022; 9:ofac583. [PMID: 36408468 PMCID: PMC9669455 DOI: 10.1093/ofid/ofac583] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Based primarily on in vitro and animal models, with little data directly addressing patient outcomes, current guidelines recommend treating staphylococcal prosthetic valve endocarditis (PVE) with antibiotic combinations including gentamicin and rifampin. Here, we synthesize the clinical data on adjunctive rifampin and gentamicin in staphylococcal PVE. METHODS We conducted a systematic review and meta-analysis of PubMed- and Cochrane-indexed studies reporting outcomes of staphylococcal PVE treated with adjunctive rifampin, gentamicin, both agents, or neither (ie, glycopeptide or β-lactam monotherapy). We recorded outcomes including mortality, relapsed infection, length of stay, nephrotoxicity, hepatotoxicity, and important drug-drug interactions (DDIs). RESULTS Four relevant studies were identified. Two studies (n = 117) suggested that adding gentamicin to rifampin-containing regimens did not reduce clinical failure (odds ratio [OR], 0.98 [95% confidence interval {CI}, .39-2.46]), and 2 studies (n = 201) suggested that adding rifampin to gentamicin-containing regimens did not reduce clinical failure (OR, 1.29 [95% CI, .71-2.33]). Neither gentamicin nor rifampin was associated with reduced infection relapse; 1 study found that rifampin treatment was associated with longer hospitalizations (mean, 31.3 vs 42.3 days; P < .001). Comparative safety outcomes were rarely reported, but 1 study found rifampin to be associated with hepatoxicity, nephrotoxicity, and DDIs, leading to treatment discontinuation in 31% of patients. CONCLUSIONS The existing clinical data do not suggest a benefit of either adjunctive gentamicin or rifampin in staphylococcal PVE. Given that other studies also suggest these agents add nephrotoxicity, hepatoxicity, and risk of DDIs without benefit in staphylococcal endovascular infections, we suggest that recommendations for gentamicin and rifampin in PVE be downgraded and primarily be used within the context of clinical trials.
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Affiliation(s)
- Jonathan H Ryder
- Correspondence: Jonathan H. Ryder, MD, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198 ()
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, Pennsylvania, USA
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Irani Thevarajan
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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Beck A, Persaud N, Tessier LA, Grad R, Kidd MR, Klarenbach S, Korownyk C, Moore A, Thombs BD, Mangin D, McCracken RK, McDonald EG, Sirois C, Kanji S, Molnar F, Nicholls SG, Thavorn K, Bennett A, Shaver N, Skidmore B, Mitchelmore BR, Avey M, Rolland-Harris E, Little J, Moher D. Interventions to address potentially inappropriate prescriptions and over-the-counter medication use among adults 65 years and older in primary care settings: protocol for a systematic review. Syst Rev 2022; 11:225. [PMID: 36266708 PMCID: PMC9585747 DOI: 10.1186/s13643-022-02044-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/01/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE To inform recommendations by the Canadian Task Force on Preventive Health Care on potentially inappropriate prescribing and over-the-counter (OTC) medication use among adults aged 65 years and older in primary care settings. This protocol outlines the planned scope and methods for a systematic review of the benefits and harms and acceptability of interventions to reduce potentially inappropriate prescriptions and OTC medication use. METHODS De novo systematic reviews will be conducted to synthesize the available evidence on (a) the benefits and harms of interventions to reduce potentially inappropriate prescriptions and OTC medications compared to no intervention, usual care, or non- or minimally active intervention among adults aged 65 years and older and (b) the acceptability of these interventions or attributes among patients. Outcomes of interest for the benefits and harms review are all-cause mortality, hospitalization, non-serious adverse drug reactions, quality of life, emergency department visits, injurious falls, medical visits, and the number of medications (and number of pills). Outcomes for the acceptability review are the preference for and relative importance of different interventions or their attributes. For the benefits and harms review, we will search MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials. For the acceptability review, we will search MEDLINE, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database for experimental and observational studies with a comparator. Websites of relevant organizations, other grey literature sources, and reference lists of included studies and reviews will be searched. Title and abstract screening will be completed by two independent reviewers using the liberal accelerated approach. Full-text review, data extraction, risk of bias assessments, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers, with any disagreements resolved by consensus or by consulting with a third reviewer. The GRADE approach will be used to assess the certainty of the evidence for outcomes. DISCUSSION The results of this systematic review will be used by the Canadian Task Force on Preventive Health Care to inform their recommendation on potentially inappropriate prescribing and OTC medication use among adults aged 65 years and older. SYSTEMATIC REVIEW REGISTRATION PROSPERO (KQ1: CRD42022302313; KQ2: CRD42022302324); Open Science Framework ( https://osf.io/urj4b/ ).
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Affiliation(s)
- Andrew Beck
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Navindra Persaud
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Laure A Tessier
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Michael R Kidd
- College of Health & Medicine, The Australian National University, Canberra, Australia.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Scott Klarenbach
- Department of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christina Korownyk
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ainsley Moore
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Brett D Thombs
- Lady Davis Institute of the Jewish General Hospital and Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of General Practice, University of Otago, Dunedin, New Zealand
| | - Rita K McCracken
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily G McDonald
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Laval University; Centre d'excellence sur le vieillissement de Québec, VITAM research Centre, Québec, Québec, Canada
| | - Salmaan Kanji
- The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Frank Molnar
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Geriatric Medicine, The Ottawa Hospital, The Ottawa Hospital Research Institute, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Alexandria Bennett
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicole Shaver
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | - Bradley R Mitchelmore
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Marc Avey
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | | | - Julian Little
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Moher
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Sekhon H, Lavin P, Vacaflor B, Rigas C, Cinalioglu K, Su CL, Bodenstein K, Dikaios E, Goodman A, Raymond FC, Ibrahim M, Bein M, Gruber J, Se J, Sasi N, Walsh C, Nazar R, Hanganu C, Berkani S, Royal I, Schiavetto A, Looper K, Launay C, McDonald EG, Seitz D, Kumar S, Beauchet O, Khoury B, Bouchard S, Battistini B, Fallavollita P, Miresco M, Bruneau MA, Vahia I, Bukhari S, Rej S. Isolating together during COVID-19: Results from the Telehealth Intervention Program for older adults. Front Med (Lausanne) 2022; 9:948506. [PMID: 36304184 PMCID: PMC9592737 DOI: 10.3389/fmed.2022.948506] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/20/2022] [Indexed: 11/27/2022] Open
Abstract
Background A pressing challenge during the COVID-19 pandemic and beyond is to provide accessible and scalable mental health support to isolated older adults in the community. The Telehealth Intervention Program for Older Adults (TIP-OA) is a large-scale, volunteer-based, friendly telephone support program designed to address this unmet need. Methods A prospective cohort study of 112 TIP-OA participants aged ≥60 years old was conducted in Quebec, Canada (October 2020–June 2021). The intervention consisted of weekly friendly phone calls from trained volunteers. The primary outcome measures included changes in scores of stress, depression, anxiety, and fear surrounding COVID-19, assessed at baseline, 4 and 8-weeks. Additional subgroup analyses were performed with participants with higher baseline scores. Results The subgroup of participants with higher baseline depression scores (PHQ9 ≥10) had significant improvements in depression scores over the 8-week period measured [mean change score = −2.27 (±4.76), 95%CI (−3.719, −0.827), p = 0.003]. Similarly, participants with higher baseline anxiety scores (GAD7 ≥10) had an improvement over the same period, which, approached significance (p = 0.06). Moreover, despite peaks in the pandemic and related stressors, our study found no significant (p ≥ 0.09) increase in stress, depression, anxiety or fear of COVID-19 scores. Discussion This scalable, volunteer-based, friendly telephone intervention program was associated with decreased scores of depression and anxiety in older adults who reported higher scores at baseline (PHQ 9 ≥10 and GAD7 ≥10).
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Affiliation(s)
- Harmehr Sekhon
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada,McLean Hospital, Harvard Medical School, Boston, MA, United States,*Correspondence: Harmehr Sekhon
| | - Paola Lavin
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | - Blanca Vacaflor
- GeriPARTy Research Lab, Montreal, QC, Canada,Pierre-Boucher Hospital, Longueuil, QC, Canada
| | - Christina Rigas
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | - Karin Cinalioglu
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | | | - Katie Bodenstein
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | | | - Allana Goodman
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | | | | | - Magnus Bein
- GeriPARTy Research Lab, Montreal, QC, Canada
| | | | - Jade Se
- GeriPARTy Research Lab, Montreal, QC, Canada
| | - Neeti Sasi
- GeriPARTy Research Lab, Montreal, QC, Canada
| | - Chesley Walsh
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | - Rim Nazar
- GeriPARTy Research Lab, Montreal, QC, Canada
| | - Cezara Hanganu
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | - Sonia Berkani
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Isabelle Royal
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | | | - Karl Looper
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Cyrille Launay
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | | | - Dallas Seitz
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Sanjeev Kumar
- Geriatric Clinical Research, The Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Olivier Beauchet
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Bassam Khoury
- Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - Stephane Bouchard
- Department of Psychoeducation and Psychology, Université du Quebec en Outaouais, Gatineau, QC, Canada
| | - Bruno Battistini
- Quebec Heart and Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada
| | - Pascal Fallavollita
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Marc Miresco
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | | | - Ipsit Vahia
- McLean Hospital, Harvard Medical School, Boston, MA, United States
| | - Syeda Bukhari
- Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
| | - Soham Rej
- Department of Psychiatry, McGill University, Montreal, QC, Canada,Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada,GeriPARTy Research Lab, Montreal, QC, Canada
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Valerio V, Rampakakis E, Zanos TP, Levy TJ, Shen HC, McDonald EG, Frenette C, Bernatsky S, Hudson M, Ward BJ, Colmegna I. High Frequency of COVID-19 Vaccine Hesitancy among Canadians Immunized for Influenza: A Cross-Sectional Survey. Vaccines (Basel) 2022; 10:vaccines10091514. [PMID: 36146592 PMCID: PMC9506006 DOI: 10.3390/vaccines10091514] [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: 08/10/2022] [Revised: 08/28/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
We assessed the frequency and correlates of COVID-19 vaccine hesitancy before Canada's vaccine rollout. A cross-sectional vaccine hesitancy survey was completed by consecutive patients/family members/staff who received the influenza vaccine at McGill University affiliated hospitals. Based on the self-reported likelihood of receiving a future vaccine (scale 0-10), the following three groups were defined: non-hesitant (score 10), mildly hesitant (7.1-9.9), and significantly hesitant (0-7). Factors associated with vaccine hesitancy were assessed with multivariate logistic regression analyses and binomial logistic regression machine learning modelling. The survey was completed by 1793 people. Thirty-seven percent of participants (n = 669) were hesitant (mildly: 315 (17.6%); significantly: 354 (19.7%)). Lower education levels, opposition and uncertainty about vaccines being mandatory, feelings of not receiving enough information about COVID-19 prevention, perceived social pressure to get a future vaccine, vaccine safety concerns, uncertainty regarding the vaccine risk-benefit ratio, and distrust towards pharmaceutical companies were factors associated with vaccine hesitancy. Vaccine safety concerns and opposition to mandatory vaccinations were the strongest correlates of vaccine hesitancy in both the logistic regressions and the machine learning model. In conclusion, in this study, over a third of people immunized for influenza before the COVID-19 vaccine rollout expressed some degree of vaccine hesitancy. Effectively addressing COVID-19 vaccine safety concerns may enhance vaccine uptake.
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Affiliation(s)
- Valeria Valerio
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
| | | | - Theodoros P. Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY 11549, USA
| | - Todd J. Levy
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA
| | - Hao Cheng Shen
- Division of General Internal Medicine, Department of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
| | - Charles Frenette
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
- Division of Infectious Diseases, Department of Medicine, The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
| | - Sasha Bernatsky
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
- Division of Rheumatology, Department of Medicine, The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H3G 1A4, Canada
| | - Marie Hudson
- Division of Rheumatology, Department of Medicine, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Brian J. Ward
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
- Division of Infectious Diseases, Department of Medicine, The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
| | - Inés Colmegna
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H4A 3J1, Canada
- Division of Rheumatology, Department of Medicine, The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC H3G 1A4, Canada
- Correspondence: ; Tel.: +1-(514)-934-1934 (ext. 35639)
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Bai AD, Lo CK, Komorowski AS, Suresh M, Guo K, Garg A, Tandon P, Senecal J, Corpo OD, Stefanova I, Fogarty C, Butler-Laporte G, McDonald EG, Cheng MP, Morris AM, Loeb M, Lee TC. Staphylococcus aureus bacteremia mortality across country income groups: A secondary analysis of a systematic review. Int J Infect Dis 2022; 122:405-411. [PMID: 35728748 DOI: 10.1016/j.ijid.2022.06.026] [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: 03/24/2022] [Revised: 05/29/2022] [Accepted: 06/14/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Staphylococcus aureus bacteremia (SAB) is a common infection worldwide. We compared SAB mortality in low- and middle-income countries (LMIC) versus high-income countries (HIC) in a meta-analysis. METHODS We searched MEDLINE, Embase, and Cochrane Database of Systematic Reviews from 1991-2021 and included observational, single-country studies on patients with positive blood cultures for S. aureus. The main outcome was the proportion of patients with SAB who died in the hospital. A generalized linear mixed random-effects model was used to pool estimates, and a meta-regression was used to adjust for study-level characteristics. RESULTS A total of 332 studies involving 517,671 patients in 39 countries were included. No study was conducted in a low-income country. Only 33 (10%) studies were performed in middle-income countries (MIC), which described 6,216 patients. The pooled in-hospital mortality was 32.4% (95% confidence interval [CI] 27.2%-38.2%, T2 = 0.3063) in MIC and 22.3% (95% CI 20.1%-24.6%, T2 = 0.3257) in HIC. In a meta-regression model, MIC had higher in-hospital mortality (adjusted odds ratio 1.37, 95% CI 1.11-1.71; P = 0.0042) than HIC. CONCLUSION In SAB studies, LMIC are poorly represented. In-hospital mortality was significantly higher in MIC than in HIC. Research should be conducted in LMIC to characterize differences in care processes driving the mortality gap.
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Affiliation(s)
- Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| | - Carson Kl Lo
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam S Komorowski
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mallika Suresh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kevin Guo
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Akhil Garg
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Pranav Tandon
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julien Senecal
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Olivier Del Corpo
- Department of Medicine, Division of Experimental Medicine, Division of Infectious Diseases, McGill University, Montréal, QC, Canada
| | - Isabella Stefanova
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Clare Fogarty
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Matthew P Cheng
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montréal, Québec, Canada
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health, University Health Network, and the University of Toronto, Toronto, Canada
| | - Mark Loeb
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Québec, Canada
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Lee TC, Murthy S, Del Corpo O, Senécal J, Butler-Laporte G, Sohani ZN, Brophy JM, McDonald EG. Remdesivir for the treatment of COVID-19: a systematic review and meta-analysis. Clin Microbiol Infect 2022; 28:1203-1210. [PMID: 35598856 PMCID: PMC9117160 DOI: 10.1016/j.cmi.2022.04.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [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: 03/16/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The benefits of remdesivir in the treatment of hospitalized patients with COVID-19 remain debated with the National Institutes of Health and the World Health Organization providing contradictory recommendations for and against use. OBJECTIVES To evaluate the role of remdesivir for hospitalized inpatients as a function of oxygen requirements. DATA SOURCES Beginning with our prior systematic review, we searched MEDLINE using PubMed from 15 January 2021 through 5 May 2022. STUDY ELIGIBILITY CRITERIA Randomised controlled trials; all languages. PARTICIPANTS All hospitalized adults with COVID-19. INTERVENTIONS Remdesivir, in comparison to either placebo, or standard of care. ASSESSMENT OF RISK OF BIAS We used the ROB-2 criteria. METHODS OF DATA SYNTHESIS The primary outcome was mortality, stratified by oxygen use (none, supplemental oxygen without mechanical ventilation, and mechanical ventilation). We conducted a frequentist random effects meta-analysis on the risk ratio scale and, to contextualize the probabilistic benefits, we also performed a Bayesian random effects meta-analysis on the risk difference scale. A ≥1% absolute risk reduction was considered clinically important. RESULTS We identified eight randomized trials, totaling 10 751 participants. The risk ratio for mortality comparing remdesivir vs. control was 0.77 (95% CI, 0.5-1.19) in the patients who did not require supplemental oxygen; 0.89 (95% CI, 0.79-0.99) for nonventilated patients requiring oxygen; and 1.08 (95% CI, 0.88-1.31) in the setting of mechanical ventilation. Using neutral priors, the probabilities that remdesivir reduces mortality were 76.8%, 93.8%, and 14.7%, respectively. The probability that remdesivir reduced mortality by ≥ 1% was 77.4% for nonventilated patients requiring oxygen. CONCLUSIONS Based on this meta-analysis, there is a high probability that remdesivir reduces mortality for nonventilated patients with COVID-19 requiring supplemental oxygen therapy. Treatment guidelines should be re-evaluated.
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Affiliation(s)
- Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Corresponding author. Todd C. Lee, Royal Victoria Hospital, 1001 Decarie Blvd, Room E5.1820, Montréal H4A3J1, QC. Canada
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Olivier Del Corpo
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Julien Senécal
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Zahra N. Sohani
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada
| | - James M. Brophy
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Division of Cardiology, Department of Medicine, McGill University, Montréal, Canada
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
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McDonald EG, Lee T. Benefits of nirmatrelvir–ritonavir remain unproven for some populations. CMAJ 2022; 194:E1041. [PMID: 35918091 PMCID: PMC9481259 DOI: 10.1503/cmaj.146689-l] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Emily G McDonald
- Associate professor, Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Todd Lee
- Associate professor, Department of Medicine, McGill University Health Centre, Montréal, Que
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Briller JE, Aggarwal NR, Davis MB, Hameed AB, Malhamé I, Mahmoud Z, McDonald EG, Moraes de Oliveira G, Quesada O, Scott NS, Sharma J. Cardiovascular Complications of Pregnancy-Associated COVID-19 Infections. JACC: Advances 2022; 1:100057. [PMID: 35967591 PMCID: PMC9364954 DOI: 10.1016/j.jacadv.2022.100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
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Girard T, Dayan N, Wilson MG, Harris M, El-Messidi A, Gosselin S, Fleiszer D, Bonnici A, Villeneuve E, Lee TC, McDonald EG. A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre. Can Pharm J (Ott) 2022; 155:277-284. [DOI: 10.1177/17151635221110153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. Objectives: We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. Methods: This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Results: Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. Conclusion: In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.
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Sohani ZN, Butler-Laporte G, Aw A, Belga S, Benedetti A, Carignan A, Cheng MP, Coburn B, Costiniuk CT, Ezer N, Gregson D, Johnson A, Khwaja K, Lawandi A, Leung V, Lother S, MacFadden D, McGuinty M, Parkes L, Qureshi S, Roy V, Rush B, Schwartz I, So M, Somayaji R, Tan D, Trinh E, Lee TC, McDonald EG. Low-dose trimethoprim-sulfamethoxazole for the treatment of Pneumocystis jirovecii pneumonia (LOW-TMP): protocol for a phase III randomised, placebo-controlled, dose-comparison trial. BMJ Open 2022; 12:e053039. [PMID: 35863836 PMCID: PMC9310160 DOI: 10.1136/bmjopen-2021-053039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection of immunocompromised hosts with significant morbidity and mortality. The current standard of care, trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 15-20 mg/kg/day, is associated with serious adverse drug events (ADE) in 20%-60% of patients. ADEs include hypersensitivity reactions, drug-induced liver injury, cytopenias and renal failure, all of which can be treatment limiting. In a recent meta-analysis of observational studies, reduced dose TMP-SMX for the treatment of PJP was associated with fewer ADEs, without increased mortality. METHODS AND ANALYSIS A phase III randomised, placebo-controlled, trial to directly compare the efficacy and safety of low-dose TMP-SMX (10 mg/kg/day of TMP) with the standard of care (15 mg/kg/day of TMP) among patients with PJP, for a composite primary outcome of change of treatment, new mechanical ventilation, or death. The trial will be undertaken at 16 Canadian hospitals. Data will be analysed as intention to treat. Primary and secondary outcomes will be compared using logistic regression adjusting for stratification and presented with 95% CI. ETHICS AND DISSEMINATION This study has been conditionally approved by the McGill University Health Centre; Ethics approval will be obtained from all participating centres. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04851015.
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Affiliation(s)
- Zahra N Sohani
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Aw
- Division of Hematology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sara Belga
- Division of Infectious Diseases, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea Benedetti
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alex Carignan
- Division of Microbiology and Infectious Diseases, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Matthew P Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Bryan Coburn
- Division of Infectious Diseases, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Cecilia T Costiniuk
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
| | - Nicole Ezer
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Respirology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Gregson
- Departments of Pathology and Laboratory Medicine and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Johnson
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kosar Khwaja
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander Lawandi
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Victor Leung
- Department of Laboratory Medicine & Pathology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sylvain Lother
- Department of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek MacFadden
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michaeline McGuinty
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Leighanne Parkes
- Division of Medical Microbiology and Infectious Diseases, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Salman Qureshi
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Division of Respirology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Valerie Roy
- Division of Microbiology and Infectious Diseases, Centre Hospitalier Universitaire de Sherbrooke Hôtel-Dieu, Sherbrooke, Quebec, Canada
| | - Barret Rush
- Department of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ilan Schwartz
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
| | - Ranjani Somayaji
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darrell Tan
- Division of Infectious Diseases, St Michael's Hospital, Toronto, Ontario, Canada
| | - Emilie Trinh
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Montreal, Quebec, Canada
| | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Montreal, Quebec, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Ross SB, Bortolussi-Courval É, Hanula R, Lee TC, Goodwin Wilson M, McDonald EG. Drug Interactions With Nirmatrelvir-Ritonavir in Older Adults Using Multiple Medications. JAMA Netw Open 2022; 5:e2220184. [PMID: 35793089 PMCID: PMC9260479 DOI: 10.1001/jamanetworkopen.2022.20184] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 12/18/2022] Open
Abstract
This quality improvement study uses data from the MedSafer trial to evaluate drug-drug interactions between nirmatrelvir-ritonavir and maintenance medications to identify use of potentially inappropriate medications in older adults with polypharmacy.
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Affiliation(s)
- Sydney B. Ross
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Émilie Bortolussi-Courval
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ryan Hanula
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd Campbell Lee
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marnie Goodwin Wilson
- Division of General Internal Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily G. McDonald
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Williams J, Gingras MA, Dubé R, Lee TC, McDonald EG. Patient empowerment brochures to increase gabapentinoid deprescribing: protocol for the prospective, controlled before-and-after GABA-WHY trial. CMAJ Open 2022; 10:E652-E656. [PMID: 35820684 PMCID: PMC9473286 DOI: 10.9778/cmajo.20210302] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Off-label use of gabapentinoids is common among patients admitted to hospital medical wards, who are at risk of adverse drug events. In this study, we will assess if educational brochures can increase rates of gabapentinoid deprescription among medical inpatients, compared with usual care. METHODS We describe the protocol for a prospective before-and-after trial that will take place on 5 medical wards of 2 tertiary care hospitals in Montréal, Canada. The study intervention will include distribution of educational brochures to users of gabapentinoids during hospital admission, as well as short educational sessions for medical staff on safe gabapentinoid prescribing practices. We will include patients with a gabapentinoid prescription before admission who are aged 60 years or older. Exclusion criteria are known seizure disorder, severe cognitive impairment, expected prognosis less than 3 months and inability to read English or French. The primary outcome is the rate of gabapentinoid deprescription at 8 weeks postdischarge. We aim to recruit 160 participants, with a 1:1 distribution between intervention and control groups. INTERPRETATION If successful, the use of educational brochures and staff education represents a scalable intervention to reduce gabapentinoid overuse by encouraging deprescription conversations between patients and their health care providers. Results of the study will be disseminated through publication in peer-reviewed journals and presentations at conferences. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT04855578.
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Affiliation(s)
- Jerome Williams
- Department of Medicine (Williams, Gingras, Dubé, Lee, McDonald), McGill University; Clinical Practice Assessment Unit (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Marc-Alexandre Gingras
- Department of Medicine (Williams, Gingras, Dubé, Lee, McDonald), McGill University; Clinical Practice Assessment Unit (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Robert Dubé
- Department of Medicine (Williams, Gingras, Dubé, Lee, McDonald), McGill University; Clinical Practice Assessment Unit (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Todd C Lee
- Department of Medicine (Williams, Gingras, Dubé, Lee, McDonald), McGill University; Clinical Practice Assessment Unit (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Emily G McDonald
- Department of Medicine (Williams, Gingras, Dubé, Lee, McDonald), McGill University; Clinical Practice Assessment Unit (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que.
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Rouette J, McDonald EG, Schuster T, Brophy JM, Azoulay L. Treatment and prescribing trends of antihypertensive drugs in 2.7 million UK primary care patients over 31 years: a population-based cohort study. BMJ Open 2022; 12:e057510. [PMID: 35688595 PMCID: PMC9189823 DOI: 10.1136/bmjopen-2021-057510] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe the prescribing trends of antihypertensive drugs in primary care patients and assess the trajectory of antihypertensive drug prescriptions, from first-line to third-line, in patients with hypertension according to changes to the United Kingdom (UK) hypertension management guidelines. DESIGN Population-based cohort study. SETTING AND PARTICIPANTS We used the UK Clinical Practice Research Datalink, an electronic primary care database representative of the UK population. Between 1988 and 2018, we identified all adult patients with at least one prescription for a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker or calcium channel blocker (CCB). PRIMARY AND SECONDARY OUTCOME MEASURES We estimated the period prevalence of patients with antihypertensive drug prescriptions for each calendar year over a 31-year period. Treatment trajectory was assessed by identifying patients with hypertension newly initiating an antihypertensive drug, and treatment changes were defined by a switch or add-on of a new class. This cohort was stratified before and after 2007, the year following important changes to UK hypertension management guidelines. RESULTS The cohort included 2 709 241 patients. The prevalence of primary care patients with antihypertensive drug prescriptions increased from 7.8% (1988) to 21.9% (2018) and was observed for all major classes except thiazide diuretics. Patients with hypertension initiated thiazide diuretics (36.8%) and beta-blockers (23.6%) as first-line drugs before 2007, and ACE inhibitors (39.9%) and CCBs (31.8%) after 2007. After 2007, 17.3% were not prescribed guideline-recommended first-line agents. Overall, patients were prescribed a median of 2 classes (IQR 1-2) after first-line treatment. CONCLUSION Nearly one-quarter of primary care patients were prescribed antihypertensive drugs by the end of the study period. Most patients with hypertension initiated guideline-recommended first-line agents. Not all patients, particularly females, were prescribed recommended agents however, potentially leading to suboptimal cardiovascular outcomes. Future research should aim to better understand the implication of this finding.
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Affiliation(s)
- Julie Rouette
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Tibor Schuster
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada
- Departmenf of Medicine, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
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Perri GA, Bortolussi-Courval É, Brinton CD, Berall A, Santiago AT, Morcos M, Lee TC, McDonald EG. MedSafer to Support Deprescribing for Residents of Long-Term Care: a Mixed-Methods Study. Can Geriatr J 2022; 25:175-182. [PMID: 35747414 PMCID: PMC9156423 DOI: 10.5770/cgj.25.545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Polypharmacy is prevalent in long-term care homes (LTCH) and increases the risk of adverse drug events. Feasible and effective deprescribing interventions applicable in the LTCH environment are needed. Methods We performed a mixed methods study to evaluate the feasibility, applicability, and effectiveness of an electronic deprescribing tool, MedSafer, to facilitate quarterly medication reviews (QMRs) on two pilot units in an academic long-term care home (LTCH). Chart reviews collected resident health data. The prevalence of deprescribing at a standard QMR was compared with a QMR conducted three months later with MedSafer. Feedback from physicians on their experience with MedSafer was obtained through semi-structured interviews. Results Physicians found MedSafer helpful in guiding deprescribing decisions and suggested software improvements to increase the feasibility in LTCH. The average number of medications deprescribed per resident was significantly higher at the MedSafer QMR (mean reduction = 1.1 medications, SD = 1.3) compared to the standard QMR (mean reduction = 0.5, SD = 0.9) (absolute difference of 0.5; SD 1.1; p = .02). Conclusion MedSafer has the potential to increase deprescribing in LTCHs by flagging potentially inappropriate medications. Integration in the electronic medical record might increase uptake in LTCHs. Further research should investigate the generalizability of MedSafer in a larger population and in non-academic LTCHs.
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Rasiah J, Prorok JC, Adekpedjou R, Barrie C, Basualdo C, Burns R, De Paul V, Donnelly C, Doyle A, Frank C, Dolsen S(G, Giguère A, Hsiung S, Kim P, McDonald EG, O’Grady H, Patey A, Puxty J, Racey M, Resin J, Sims-Gould J, Stewart S, Theou O, Webster S, Muscedere J. Enabling Healthy Aging to AVOID Frailty in Community Dwelling Older Canadians. Can Geriatr J 2022; 25:202-211. [PMID: 35747405 PMCID: PMC9156415 DOI: 10.5770/cgj.25.536] [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] [Indexed: 11/22/2022] Open
Abstract
The Canadian population is aging. With aging, biological and social changes occur increasing the risk of developing chronic conditions and functional loss leading to frailty. Older adults living with frailty are more vulnerable to minor stressors, take longer to recover from illness, and have difficulty participating in daily activities. The Canadian Frailty Network's (CFN) mission is to improve the lives of older adults living with frailty. In September 2019, CFN launched the Activity & Exercise, Vaccination, Optimization of medications, Interaction & Socialization, and Diet & Nutrition (AVOID) Frailty public health campaign to promote assessing and reducing risk factors leading to the development of frailty. As part of the campaign, CFN held an Enabling Healthy Aging Symposium with 36 stakeholders from across Canada. Stakeholders identified individual and community-level opportunities and challenges for the enablement of healthy aging and frailty mitigation, as part of a focused consultative process. Stakeholders ranked the three most important challenges and opportunities at the individual and community levels for implementing AVOID Frailty recommendations. Concrete actions, further research areas, policy changes, and existing resources/programs to enhance the AVOID Frailty campaign were identified. The results will help inform future priorities and behaviour change strategies for healthy aging in Canada.
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Affiliation(s)
| | | | - Rheda Adekpedjou
- Centre de Recherche du Centre Hospitalier Universitaire de Montréal, Montreal, QC
| | | | | | - Rachel Burns
- Department of Psychology, Carleton University, Ottawa, ON
| | - Vincent De Paul
- School of Rehabilitation Therapy, Queen’s University, Kingston, ON
| | | | - Amy Doyle
- Canadian Frailty Network, Kingston, ON
| | | | | | - Anik Giguère
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, QC
| | - Sonia Hsiung
- Alliance for Healthier Communities, North York, ON
| | - Perry Kim
- Canadian Frailty Network, Kingston, ON
- School of Rehabilitation Therapy, Queen’s University, Kingston, ON
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, QC
| | - Heather O’Grady
- School of Rehabilitation Science, McMaster University, Hamilton, ON
| | - Andrea Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON
| | - John Puxty
- Department of Medicine, Queen’s University, Kingston, ON
| | - Megan Racey
- McMaster Evidence Review and Synthesis Team; School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | | | - Joanie Sims-Gould
- Department of Family Practice, University of British Columbia, Vancouver, BC
| | - Susan Stewart
- Kingston Frontenac Lennox & Addington Public Health, Kingston, ON
| | - Olga Theou
- Physiotherapy and Geriatric Medicine, Dalhousie University, Halifax, NS
| | - Sarah Webster
- Centre for Studies in Aging and Health, Province Care Hospital, Toronto, ON
| | - John Muscedere
- Canadian Frailty Network, Kingston, ON
- Department of Critical Care Medicine, Queen’s University, Kingston, ON
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Moryousef J, Bortolussi-Courval É, Podymow T, Lee TC, Trinh E, McDonald EG. Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial. Can J Kidney Health Dis 2022; 9:20543581221098778. [PMID: 35586025 PMCID: PMC9109480 DOI: 10.1177/20543581221098778] [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: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background End-stage kidney disease patients on dialysis have a substantial risk of polypharmacy due their propensity for comorbidity and contact with the health care system. MedSafer is an electronic decision support tool that integrates patient comorbidity and medication lists to generate personalized deprescribing reports focused on identifying potentially inappropriate medications (PIMs). Objective To conduct a secondary analysis of patients on regular hemodialysis included in the MedSafer randomized controlled trial to investigate the patterns of polypharmacy and evaluate the efficacy of the MedSafer deprescribing algorithms. Design Secondary analysis of a cluster randomized clinical trial. Setting Medical units in 11 acute care hospitals in Canada. Patients The MedSafer trial enrolled 5698 participants with an expected prognosis of >3 months, age 65 years and older, and on 5 or more daily home medications; 140 participants were receiving chronic hemodialysis. Measurements The primary outcome of the trial was 30-day adverse drug events (ADEs) post-hospital discharge, and a key secondary outcome was deprescribing. Methods Control patients received usual care (medication reconciliation), whereas clinicians caring for intervention patients received a MedSafer report that highlighted individualized opportunities for deprescribing. Results There were 70 patients in each of the control and intervention arms. The median number of home medications was 14 (compared with a median of 10 medications in the general trial population). The most frequent medications observed that were potentially inappropriate were proton pump inhibitors (potentially inappropriate in 55/76 users; 72.4%), diabetes medications in patients with a HBA1C <7.5% (36/65 users; 55.4%), docusate (27/27 users; 100%), gabapentinoids (27/36 users; 75%), and combination antiplatelet/anticoagulants (22/97 users; 22.7%). The proportion of PIMs deprescribed was higher during the intervention phase (28.8% vs 19.3%; absolute increase 9.4% [95% confidence interval 1.3%-17.6%]) compared with the control phase. There was no observed difference in ADEs at 30-day post-discharge between the control and the intervention groups. The most common ADE (n = 3) was gastrointestinal bleeding attributed to antiplatelet agents. Limitations This was a post hoc exploratory analysis, the original trial did not stratify by hemodialysis status, and the small sample size precludes drawing any definitive conclusions. Conclusion MedSafer facilitates deprescribing in hospitalized patients on hemodialysis. Larger-scale implementation of decision support software for deprescribing in dialysis and long-term follow-up are likely required to demonstrate an impact on ADEs.
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Affiliation(s)
- Joseph Moryousef
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Tiina Podymow
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emilie Trinh
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, Department of Medicine, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
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Lee TC, Morris AM, Schwartz IS, McDonald EG. Allocated but not treated: the silent 16. Lancet 2022; 399:1775. [PMID: 35526549 PMCID: PMC9071205 DOI: 10.1016/s0140-6736(22)00377-4] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 02/22/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Todd C Lee
- Division of Infectious Diseases, McGill University, Montreal, QC H4A 3S1, Canada; Clinical Practice Assessment Unit, McGill University, Montreal, QC H4A 3S1, Canada; Department of Medicine and Royal Victoria Hospital, McGill University, Montreal, QC H4A 3S1, Canada.
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, McGill University, Montreal, QC H4A 3S1, Canada; Division of General Internal Medicine, McGill University, Montreal, QC H4A 3S1, Canada; Department of Medicine and Royal Victoria Hospital, McGill University, Montreal, QC H4A 3S1, Canada
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49
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Spellberg B, Aggrey G, Brennan MB, Footer B, Forrest G, Hamilton F, Minejima E, Moore J, Ahn J, Angarone M, Centor RM, Cherabuddi K, Curran J, Davar K, Davis J, Dong MQ, Ghanem B, Hutcheon D, Jent P, Kang M, Lee R, McDonald EG, Morris AM, Reece R, Schwartz IS, So M, Tong S, Tucker C, Wald-Dickler N, Weinstein EJ, Williams R, Yen C, Zhou S, Lee TC. Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open 2022; 5:e2211321. [PMID: 35536578 PMCID: PMC9092201 DOI: 10.1001/jamanetworkopen.2022.11321] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. OBJECTIVE To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools. EVIDENCE REVIEW This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available. FINDINGS Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy. CONCLUSIONS AND RELEVANCE The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.
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Affiliation(s)
- Brad Spellberg
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Gloria Aggrey
- Montgomery Medical Associates PC, Rockville, Maryland
| | - Meghan B. Brennan
- University of Wisconsin Hospital and Clinics, William S. Middleton Memorial Veterans Hospital, Madison
| | - Brent Footer
- Providence Portland Medical Center, Portland, Oregon
| | | | | | - Emi Minejima
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles
| | - Jessica Moore
- Providence Little Company of Mary Medical Center, San Pedro, California
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor
| | | | - Robert M. Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama
| | | | - Jennifer Curran
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Kusha Davar
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Joshua Davis
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Mei Qin Dong
- New York Health and Hospitals Bellevue Hospital, New York, New York
| | | | - Doug Hutcheon
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Philipp Jent
- Department of Infectious Diseases, Inselspital Bern University Hospital, Bern, Switzerland
| | - Minji Kang
- University of Texas Southwestern, Dallas
| | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Canada
| | - Andrew M. Morris
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
| | - Rebecca Reece
- Section of Infectious Diseases, Department of Medicine, West Virginia University School of Medicine, Morgantown
| | - Ilan S. Schwartz
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, UHN and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Steven Tong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital and University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Christopher Tucker
- Hospital Medicine, Magnolia Regional Health Center, Corinth, Mississippi
| | - Noah Wald-Dickler
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Erica J. Weinstein
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Riley Williams
- Pharmacy Service, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
| | | | - Shiwei Zhou
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Todd C. Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Canada
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Bai AD, Lo CKL, Komorowski AS, Suresh M, Guo K, Garg A, Tandon P, Senecal J, Del Corpo O, Stefanova I, Fogarty C, Butler-Laporte G, McDonald EG, Cheng MP, Morris AM, Loeb M, Lee TC. What Is the Optimal Follow-up Length for Mortality in Staphylococcus aureus Bacteremia? Observations From a Systematic Review of Attributable Mortality. Open Forum Infect Dis 2022; 9:ofac096. [PMID: 35415199 PMCID: PMC8995072 DOI: 10.1093/ofid/ofac096] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/19/2022] [Indexed: 11/14/2022] Open
Abstract
Background Deaths following Staphylococcus aureus bacteremia (SAB) may be related or unrelated to the infection. In SAB therapeutics research, the length of follow-up should be optimized to capture most attributable deaths and minimize nonattributable deaths. We performed a secondary analysis of a systematic review to describe attributable mortality in SAB over time. Methods We systematically searched Medline, Embase, and Cochrane Database of Systematic Reviews from 1 January 1991 to 7 May 2021 for human observational studies of SAB. To be included in this secondary analysis, the study must have reported attributable mortality. Two reviewers extracted study data and assessed risk of bias independently. Pooling of study estimates was not performed due to heterogeneity in the definition of attributable deaths. Results Twenty-four observational cohort studies were included. The median proportion of all-cause deaths that were attributable to SAB was 77% (interquartile range [IQR], 72%–89%) at 1 month and 62% (IQR, 58%–75%) at 3 months. At 1 year, this proportion was 57% in 1 study. In 2 studies that described the rate of increase in mortality over time, 2-week follow-up captured 68 of 79 (86%) and 48 of 57 (84%) attributable deaths that occurred by 3 months. By comparison, 1-month follow-up captured 54 of 57 (95%) and 56 of 60 (93%) attributable deaths that occurred by 3 months in 2 studies. Conclusions The proportion of deaths that are attributable to SAB decreases as follow-up lengthens. Follow-up duration between 1 and 3 months seems optimal if evaluating processes of care that impact SAB mortality. Clinical Trials Registration PROSPERO CRD42021253891.
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Affiliation(s)
- Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Carson K L Lo
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam S Komorowski
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mallika Suresh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kevin Guo
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Akhil Garg
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Pranav Tandon
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julien Senecal
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Olivier Del Corpo
- Department of Medicine, Division of Experimental Medicine, Division of Infectious Diseases, McGill University, Montreal, Quebec, Canada
| | - Isabella Stefanova
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Clare Fogarty
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew P Cheng
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health, University Health Network, and the University of Toronto, Toronto, Ontario, Canada
| | - Mark Loeb
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
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