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Perlas A, Xiao MZX, Tomlinson G, Jacob B, Abdullah S, Kruisselbrink R, Chan VWS. Baseline Gastric Volume in Fasting Diabetic Patients Is Not Higher than That in Nondiabetic Patients: A Cross-sectional Noninferiority Study. Anesthesiology 2024; 140:648-656. [PMID: 37883294 DOI: 10.1097/aln.0000000000004815] [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] [Indexed: 10/28/2023]
Abstract
BACKGROUND The physiology of diabetes mellitus can increase the risk of perioperative aspiration, but there is limited and contradictory evidence on the incidence of "full stomach" in fasting diabetic patients. The aim of this study is to assess the baseline gastric content (using gastric ultrasound) in diabetic and nondiabetic patients scheduled for elective surgery who have followed standard preoperative fasting instructions. METHODS This was a prospective, noninferiority study of 180 patients (84 diabetic and 96 nondiabetic patients). Bedside ultrasound was used for qualitative and quantitative assessment of the gastric antrum in the supine and right lateral decubitus positions. Fasting gastric volume was estimated based on the cross-sectional area of the gastric antrum and a validated model. The hypothesis was that diabetic patients would not have a higher baseline fasting gastric volume compared to nondiabetic patients, with a noninferiority margin of 0.4 ml/kg. Secondary aims included the comparison of the incidence of full stomach (solid content or more than 1.5 mL/kg of clear fluid), estimation of the 95th percentile of the gastric volume distribution in both groups, and examination of the association between gastric volume, glycemic control, and diabetic comorbidities. RESULTS The baseline gastric volume was not higher in diabetic patients (0.81 ± 0.61 ml/kg) compared to nondiabetic patients (0.87 ± 0.53 ml/kg) with a mean difference of -0.07 ml/kg (95% CI, -0.24 to 0.10 ml/kg). A total of 13 (15.5%) diabetic and 11 (11.5%) nondiabetic patients presented more than 1.5 ml/kg of gastric volume (95% CI for difference, -7.1 to 15.2%). There was little correlation between the gastric volume and either the time since diagnosis or HbA1C. CONCLUSIONS The data suggest that the baseline gastric volume in diabetic patients who have followed standard fasting instructions is not higher than that in nondiabetic patients. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Anahi Perlas
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; and Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - George Tomlinson
- Biostatistical Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Binu Jacob
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sara Abdullah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Vincent W S Chan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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Benseler A, Tomlinson G, Lovatsis D, Alarab M, McDermott CD. Optimizing practices to prevent urinary tract infection after cystoscopy and urodynamics in women: A quality improvement study. Neurourol Urodyn 2024; 43:883-892. [PMID: 38501377 DOI: 10.1002/nau.25447] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/28/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE The objective of this study was to reduce the incidence of urinary tract infection (UTI) in women undergoing outpatient cystoscopy and/or urodynamic studies (UDS) at our centre by identifying and then altering modifiable risk factors through an analysis of incidence variability among physicians. METHODS This was a quality improvement study involving adult women undergoing outpatient cystoscopy and/or UDS at an academic tertiary urogynecology practice. Prophylactic practices for cystoscopy/UDS were surveyed and division and physician-specific UTI rates following cystoscopy/UDS were established. In consultation with key stakeholders, this delineated change concepts based on associations between prophylactic practices and UTI incidence, which were then implemented while monitoring counterbalance measures. RESULTS Two "Plan-Do-Study-Act-Cycles" were conducted whereby 212 and 210 women were recruited, respectively. Change concepts developed and implemented were: (1) to perform routine urine cultures at the time of these outpatient procedures, and (2) to withhold routine prophylactic antibiotics for outpatient cystoscopy/UDS, except in patients with signs of cystitis. There was no change in the incidence of early presenting UTI (9.0% vs. 9.2%, p = 0.680), but there were significantly fewer antibiotic-related adverse events reported (8.5% vs. 1.5%, p = 0.001). There was no significant change in the total incidence of UTI rates between cycles (7.8% vs. 5.6%, p = 0.649). CONCLUSIONS No specific strategies to decrease the incidence of UTI following outpatient cystoscopy/UDS were identified, however, risk factor-specific antibiotic prophylaxis, as opposed to universal antibiotic prophylaxis, did not increase UTI incidence.
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Affiliation(s)
- Anouk Benseler
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network and Mount Sinai Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Danny Lovatsis
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - May Alarab
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colleen D McDermott
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Urogynecology, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Parthipan M, Feng G, Breunis H, Timilshina N, Emmenegger U, Hansen A, Tomlinson G, Matthew A, Clarke H, Santa Mina D, Soto-Perez-de-Celis E, Puts M, Alibhai SMH. Understanding the incidence, duration, and severity of symptoms through daily symptom monitoring among frail and non-frail older patients receiving metastatic prostate cancer treatments. J Geriatr Oncol 2024; 15:101720. [PMID: 38350343 DOI: 10.1016/j.jgo.2024.101720] [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: 09/01/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/15/2024]
Abstract
INTRODUCTION Older adults with metastatic prostate cancer (mPC) experience high symptom burden associated with treatment. Frailty may exacerbate treatment toxicity. The aim of this study was to explore short-term treatment toxicity in patients with metastatic prostate cancer. MATERIALS AND METHODS Older adults with metastatic prostate cancer starting chemotherapy, androgen-receptor-axis targeted therapies, or radium-223 participated in a prospective, multicentre, observational study. Participants self-reported symptoms daily using the Edmonton Symptom Assessment System for one treatment cycle via internet or telephone. The most common moderate-to-severe symptoms (score≥4), their duration, and the proportion of participants who experienced improvements in symptom severity (score<4) after reporting moderate-to-severe symptoms at baseline were determined using descriptive statistics. Once-weekly symptom questionnaires were administered and analyzed using linear mixed effect models. Symptom incidence, duration, and frailty associations were assessed using t-tests and chi-square tests. RESULTS Ninety participants completed the study (mean age=77 years [standard deviation=6.1], 42% frail [Vulnerable Elders Survey≥3]). The most common moderate-to-severe symptoms across cohorts were fatigue (46.8%), insomnia (42.9%), poor wellbeing (41.2%), pain (37.5%), and decreased appetite (37.1%). Poor wellbeing had a higher incidence in frail participants (62.5% in frail vs. 31.4% in non-frail, p=0.039). Symptom duration varied across cohorts and between frail and non-frail participants. Among participants who reported moderate-to-severe symptoms at baseline, no more than 15% improved in any symptom. There were statistically significant improvements in weekly symptoms for fatigue, decreased appetite, and insomnia in the chemotherapy cohort only. DISCUSSION Limitations include a short follow-up duration, lack of a control group, and few radium-223 participants. Regular symptom monitoring can help clinicians understand temporal patterns and durations of symptoms and inform supportive care approaches.
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Affiliation(s)
| | - Gregory Feng
- Department of Medicine, University Health Network, Toronto, Canada
| | | | | | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Toronto, Canada
| | - Aaron Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - George Tomlinson
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Andrew Matthew
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada
| | - Hance Clarke
- Department of Anesthesia, Toronto General Hospital, Toronto, Canada
| | - Daniel Santa Mina
- ELLICSR: Health, Wellness and Cancer Survivorship Centre, University Health Network, Toronto, Canada
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
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Dale NM, Hagre YD, Dcbtanne L, Tomlinson G, Shepherd S, Zlotkin S, Parshuram C. Comparing manual versus multi-model pulse oximeter measurements for temperature and respiratory rate in malnourished children. Acta Paediatr 2024. [PMID: 38529834 DOI: 10.1111/apa.17216] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/14/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Nancy M Dale
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Center for Safety Research, Toronto, Ontario, Canada
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Youssouf Djidita Hagre
- Mother-Child Teaching Hospital (MCTH) and Faculty of Health Science, University of Ndjamena, Ndjamena, Chad
| | | | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Christopher Parshuram
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Center for Safety Research, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Lovblom LE, Briollais L, Perkins BA, Tomlinson G. Modeling multiple correlated end-organ disease trajectories: A tutorial for multistate and joint models with applications in diabetes complications. Stat Med 2024; 43:1048-1082. [PMID: 38118464 DOI: 10.1002/sim.9984] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/22/2023]
Abstract
State-of-the-art biostatistics methods allow for the simultaneous modeling of several correlated non-fatal disease processes over time, but there is no clear guidance on the optimal analysis in most settings. An example occurs in diabetes, where it is not known with certainty how microvascular complications of the eyes, kidneys, and nerves co-develop over time. In this article, we propose and contrast two general model frameworks for studying complications (sequential state and parallel trajectory frameworks) and review multivariate methods for their analysis, focusing on multistate and joint modeling. We illustrate these methods in a tutorial format using the long-term follow-up from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications study public data repository. A formal comparison of prediction error and discrimination is included. Multistate models are particularly advantageous for determining the order and timing of complications, but require discretization of the longitudinal outcomes and possibly a very complex state space process. Intermittent observation of the states must be accounted for, and discretization is a probable disadvantage in this setting. In contrast, joint models can account for variations of continuous biomarkers over time and are particularly designed for modeling complex association structures between the complications and for performing dynamic predictions of an outcome of interest to inform clinical decisions (eg, a late-stage complication). We found that both models have helpful features that can better-inform our understanding of the complex trajectories that complications may take and can therefore help with decision making for patients presenting with diabetes complications.
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Affiliation(s)
- Leif Erik Lovblom
- Biostatistics Department, University Health Network, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Laurent Briollais
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
- Leadership Sinai Centre for Diabetes, Sinai Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine at UHN/Sinai Health, University of Toronto, Toronto, Ontario, Canada
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Quickfall D, Sklar MC, Tomlinson G, Orchanian-Cheff A, Goligher EC. The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis. EClinicalMedicine 2024; 68:102417. [PMID: 38235422 PMCID: PMC10789641 DOI: 10.1016/j.eclinm.2023.102417] [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: 09/12/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation. Methods This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools. Findings Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume. Interpretation Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients. Funding This study did not receive any funding support.
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Affiliation(s)
- Danica Quickfall
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Michael C. Sklar
- Unity Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
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Abdelmalek FM, Angriman F, Moore J, Liu K, Burry L, Seyyed-Kalantari L, Mehta S, Gichoya J, Celi LA, Tomlinson G, Fralick M, Yarnell CJ. Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States. Ann Am Thorac Soc 2024; 21:287-295. [PMID: 38029405 DOI: 10.1513/annalsats.202305-485oc] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.
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Affiliation(s)
| | - Federico Angriman
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Julie Moore
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Kuan Liu
- Institute of Health Policy, Management, and Evaluation
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine
- Leslie Dan Faculty of Pharmacy, and
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Laleh Seyyed-Kalantari
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Judy Gichoya
- Department of Radiology and Biomedical Informatics, Emory University, Atlanta, Georgia
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George Tomlinson
- Institute of Health Policy, Management, and Evaluation
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Michael Fralick
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Christopher J Yarnell
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
- Department of Critical Care Medicine and
- Scarborough Health Network Research Institute, Scarborough Health Network, Toronto, Ontario, Canada
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Bradley TD, Logan AG, Lorenzi Filho G, Kimoff RJ, Durán Cantolla J, Arzt M, Redolfi S, Parati G, Kasai T, Dunlap ME, Delgado D, Yatsu S, Bertolami A, Pedrosa R, Tomlinson G, Marin Trigo JM, Tantucci C, Floras JS. Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial. Lancet Respir Med 2024; 12:153-166. [PMID: 38142697 DOI: 10.1016/s2213-2600(23)00374-0] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND In patients with heart failure and reduced ejection fraction, sleep-disordered breathing, comprising obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is associated with increased morbidity, mortality, and sleep disruption. We hypothesised that treating sleep-disordered breathing with a peak-flow triggered adaptive servo-ventilation (ASV) device would improve cardiovascular outcomes in patients with heart failure and reduced ejection fraction. METHODS We conducted a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial of peak-flow triggered ASV in patients aged 18 years or older with heart failure and reduced ejection fraction (left ventricular ejection fraction ≤45%) who were stabilised on optimal medical therapy with co-existing sleep-disordered breathing (apnoea-hypopnoea index [AHI] ≥15 events/h of sleep), with concealed allocation and blinded outcome assessments. The trial was carried out at 49 hospitals in nine countries. Sleep-disordered breathing was stratified into predominantly OSA with an Epworth Sleepiness Scale score of 10 or lower or predominantly CSA. Participants were randomly assigned to standard optimal treatment alone or standard optimal treatment with the addition of ASV (1:1), stratified by study site and sleep apnoea type (ie, CSA or OSA), with permuted blocks of sizes 4 and 6 in random order. Clinical evaluations were performed and Minnesota Living with Heart Failure Questionnaire, Epworth Sleepiness Scale, and New York Heart Association class were assessed at months 1, 3, and 6 following randomisation and every 6 months thereafter to a maximum of 5 years. The primary endpoint was the cumulative incidence of the composite of all-cause mortality, first admission to hospital for a cardiovascular reason, new onset atrial fibrillation or flutter, and delivery of an appropriate cardioverter-defibrillator shock. All-cause mortality was a secondary endpoint. Analysis for the primary outcome was done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT01128816) and the International Standard Randomised Controlled Trial Number Register (ISRCTN67500535), and the trial is complete. FINDINGS The first and last enrolments were Sept 22, 2010, and March 20, 2021. Enrolments terminated prematurely due to COVID-19-related restrictions. 1127 patients were screened, of whom 731 (65%) patients were randomly assigned to receive standard care (n=375; mean AHI 42·8 events per h of sleep [SD 20·9]) or standard care plus ASV (n=356; 43·3 events per h of sleep [20·5]). Follow-up of all patients ended at the latest on June 15, 2021, when the trial was terminated prematurely due to a recall of the ASV device due to potential disintegration of the motor sound-abatement material. Over the course of the trial, 41 (6%) of participants withdrew consent and 34 (5%) were lost to follow-up. In the ASV group, the mean AHI decreased to 2·8-3·7 events per h over the course of the trial, with associated improvements in sleep quality assessed 1 month following randomisation. Over a mean follow-up period of 3·6 years (SD 1·6), ASV had no effect on the primary composite outcome (180 events in the control group vs 166 in the ASV group; hazard ratio [HR] 0·95, 95% CI 0·77-1·18; p=0·67) or the secondary endpoint of all-cause mortality (88 deaths in the control group vs. 76 in the ASV group; 0·89, 0·66-1·21; p=0·47). For patients with OSA, the HR for all-cause mortality was 1·00 (0·68-1·46; p=0·98) and for CSA was 0·74 (0·44-1·23; p=0·25). No safety issue related to ASV use was identified. INTERPRETATION In patients with heart failure and reduced ejection fraction and sleep-disordered breathing, ASV had no effect on the primary composite outcome or mortality but eliminated sleep-disordered breathing safely. FUNDING Canadian Institutes of Health Research and Philips RS North America.
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Affiliation(s)
- T Douglas Bradley
- University Health Network Toronto Rehabilitation Institute (KITE), Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada.
| | - Alexander G Logan
- Toronto General Hospital, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
| | | | - R John Kimoff
- McGill University Health Centre, Montreal, QC, Canada
| | | | - Michael Arzt
- Universitaetskinikum Regensburg, Regensburg, Germany
| | | | - Gianfranco Parati
- IRCCS, Istituto Auxologico Italiano, Milan, Italy; University of Milano-Bicocca, Milan, Italy
| | | | - Mark E Dunlap
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | | | - Shoichiro Yatsu
- University Health Network Toronto Rehabilitation Institute (KITE), Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada
| | | | | | | | | | | | - John S Floras
- Toronto General Hospital, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
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Lok CE, Hemmelgarn BR, Moist LM, Polkinghorne K, Tomlinson G, Tonelli M. Protection against Incidences of Serious Cardiovascular Events Study with daily fish oil supplementation in dialysis patients (PISCES): protocol for a randomised controlled trial. BMJ Open 2024; 14:e072239. [PMID: 38199618 PMCID: PMC10806752 DOI: 10.1136/bmjopen-2023-072239] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/19/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Patients with kidney failure with replacement therapy (KFRT) suffer premature cardiovascular (CV) mortality and events with few proven pharmacological interventions. Omega-3 polyunsaturated essential fatty acids (n-3 PUFAs) are associated with a reduced risk of CV events and death in non-dialysis patients and in patients with established CV disease but n-3 PUFAs have not been evaluated in the high risk KFRT patient population. METHODS AND ANALYSIS This multicentre randomised, placebo controlled, parallel pragmatic clinical trial tests the hypothesis that oral supplementation with n-3 PUFA, when added to usual care, leads to a reduction in the rate of serious CV events in haemodialysis patients when compared with usual care plus matching placebo. A target sample size of 1100 KFRT patients will be recruited from 26 dialysis units in Canada and Australia and randomised to n-3 PUFA or matched placebo in a 1:1 ratio with an expected intervention period of at least 3.5 years. The primary outcome to be analysed and compared between intervention groups is the rate of all, not just the first, serious CV events which include sudden and non-sudden cardiac death, fatal and non-fatal myocardial infarction, stroke, and peripheral vascular disease events. ETHICS AND DISSEMINATION This study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. TRIAL REGISTRATION NUMBER ISRCTN00691795.
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Affiliation(s)
- Charmaine E Lok
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | | | - Louise M Moist
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Kevan Polkinghorne
- Department of Medicine, Monash University, Clayton, Melbourne, Australia
| | - George Tomlinson
- Department of Medicine, Toronto General Hospital Research Insitute, Toronto, Ontario, Canada
| | - Marcello Tonelli
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
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10
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Tomlinson G, Al-Khafaji A, Conrad SA, Factora FNF, Foster DM, Galphin C, Gunnerson KJ, Khan S, Kohli-Seth R, McCarthy P, Meena NK, Pearl RG, Rachoin JS, Rains R, Seneff M, Tidswell M, Walker PM, Kellum JA. Correction to: Bayesian methods: a potential path forward for sepsis trials. Crit Care 2024; 28:11. [PMID: 38172963 PMCID: PMC10765909 DOI: 10.1186/s13054-023-04791-1] [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] [Indexed: 01/05/2024] Open
Affiliation(s)
- George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health, Shreveport, LA, USA
| | - Faith N F Factora
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Claude Galphin
- Southeast Renal Research Institute, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Sobia Khan
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul McCarthy
- West Virginia University, Heart & Vascular Institute, Morgantown, WV, USA
| | - Nikhil K Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ronald Rains
- Pulmonary Associates, Univ of Colorado Health-Memorial Hospital, Colorado Springs, CO, USA
| | - Michael Seneff
- Department of Anesthesia and Critical Care, George Washington University Hospital, Washington, DC, USA
| | - Mark Tidswell
- Pulmonary and Critical Care Division, Baystate Medical Center, Springfield, MA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
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11
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Abdulrehman J, Forté S, Tomlinson G, Solh Z, Bolster L, Sun HL, Bartolucci P, Kuo KHM. THromboprophylaxis In Sickle Cell Disease with central venous catheters (THIS): an internal pilot randomised controlled trial protocol. BMJ Open 2024; 14:e079363. [PMID: 38171625 PMCID: PMC10773310 DOI: 10.1136/bmjopen-2023-079363] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Individuals with sickle cell disease (SCD) and central venous catheters (CVC) are at high risk for venous thromboembolism (VTE). Minimal data exist regarding the use of anticoagulation as thromboprophylaxis of VTE in this demographic, and as a result, clinical equipoise exists. Prophylactic dose rivaroxaban, a direct oral anticoagulant, is efficacious and safe as thromboprophylaxis in other demographics, and may be an optimal agent in SCD with CVC. Prior to conducting a full clinical trial to assess rivaroxaban as thromboprophylaxis in SCD with CVC, a pilot study is needed to gauge its feasibility. METHODS AND ANALYSIS THromboprophylaxis In Sickle Cell Disease pilot trial is an investigator-initiated, multicentre, double-blinded, randomised controlled trial (RCT) assessing if it is feasible and safe to conduct an adequately powered RCT comparing rivaroxaban to matching placebo as thromboprophylaxis in those with SCD and CVC. Fifty adult patients with SCD and CVC will be randomised to receive either rivaroxaban 10 mg daily or matching placebo for the duration of the CVC in situ for up to 1 year. After randomisation, follow-up visits will occur every 3 months. The primary outcomes pertain to the feasibility of a full trial and include numbers of eligible and recruited participants. Exploratory outcomes include overall incidence of VTE and bleeding complications, as well as quality of life. If the full trial is feasible, blinding will be maintained and patients in the pilot study will be included in the full trial. ETHICS AND DISSEMINATION The trial was initially approved by the University Health Network Research Ethics Board (REB) in Toronto, Canada. All sites will obtain approval from their respective REB prior to commencement of study activities. Study results will be disseminated through presentations at medical conferences and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05033314.
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Affiliation(s)
- Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Forté
- Division of Hematology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - George Tomlinson
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ziad Solh
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lauren Bolster
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Haowei Linda Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Pablo Bartolucci
- Department of Internal Medicine, Assistance Publique Hopitaux de Paris, Creteil, France
| | - Kevin H M Kuo
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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12
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Alibhai SMH, Papadopoulos E, Mina DS, Ritvo P, Tomlinson G, Sabiston CM, Durbano S, Bremner KE, Chiarotto J, Matthew A, Warde P, O'Neill M, Culos-Reed SN. Home-based versus supervised group exercise in men with prostate cancer on androgen deprivation therapy: A randomized controlled trial and economic analysis. J Geriatr Oncol 2024; 15:101646. [PMID: 37976654 DOI: 10.1016/j.jgo.2023.101646] [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: 07/04/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Differences between health outcomes, participation/adoption, and cost-effectiveness of home-based (HOME) interventions and supervised group-based training (GROUP) in men with prostate cancer (PC) on androgen deprivation therapy (ADT) are currently unknown. The objective of this study was to assess the clinical efficacy, adherence, and cost-effectiveness of HOME versus GROUP in men on ADT for PC. MATERIALS AND METHODS This was a multicentre, 2-arm non-inferiority randomized controlled trial and companion cost-effectiveness analysis. Men with PC on ADT were recruited from August 2016 to March 2020 from four Canadian centres and randomized 1:1 to GROUP or HOME. All study participants engaged in aerobic and resistance training four to five days weekly for six months. Fatigue [Functional Assessment of Cancer Therapy-Fatigue (FACT-F)] and functional endurance [6-min walk test (6MWT)] at six months were the co-primary outcomes. Secondary outcomes included quality of life, physical fitness, body composition, blood markers, sedentary behaviour, and adherence. Between-group differences in primary outcomes were compared to margins of 3 points for FACT-F and 40 m for 6MWT using a Bayesian analysis of covariance (ANCOVA). Secondary outcomes were compared with ANCOVA, Costs included Ministry of Health costs, program costs, patient out-of-pocket, and time costs. TRIAL REGISTRATION #NCT02834416. RESULTS Thirty-eight participants (mean [standard deviation (SD)] age, 70 [9.0] years) were enrolled (GROUP n = 20; HOME n = 18). There was an 89.8% probability that HOME was non-inferior to GROUP for both fatigue and functional endurance and a 9.5% probability that HOME reduced fatigue compared to GROUP (mean [SD] change, 12.1 [8.1] vs 3.6 [6.1]; p = 0.040) at six months. Adherence was similar among study arms. HOME was cost-saving (mean difference: -$4122) relative to GROUP. DISCUSSION A HOME exercise intervention appears non-inferior to GROUP for fatigue and functional endurance and requires fewer resources to implement. HOME appears to ameliorate fatigue more than GROUP, but has comparable effects on other clinically relevant outcomes. Although limited by sample size and attrition, these results support further assessment of home-based programs.
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Affiliation(s)
- Shabbir M H Alibhai
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada.
| | | | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Paul Ritvo
- Department of Psychology, School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Catherine M Sabiston
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Sara Durbano
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Karen E Bremner
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - James Chiarotto
- Department of Medicine, Division of Hematology/Oncology, Scarborough Health Network, Scarborough, ON, Canada
| | - Andrew Matthew
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Padraig Warde
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Meagan O'Neill
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - S Nicole Culos-Reed
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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13
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Sahakyan Y, Li Q, Alibhai SM, Puts M, Yeretzian ST, Anwar MR, Brennenstuhl S, McLean B, Strohschein F, Tomlinson G, Wills A, Abrahamyan L. Cost-Utility Analysis of Geriatric Assessment and Management in Older Adults With Cancer: Economic Evaluation Within 5C Trial. J Clin Oncol 2024; 42:59-69. [PMID: 37871266 PMCID: PMC10730076 DOI: 10.1200/jco.23.00930] [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: 05/02/2023] [Revised: 07/31/2023] [Accepted: 08/22/2023] [Indexed: 10/25/2023] Open
Abstract
PURPOSE Geriatric assessment (GA) is a guideline-recommended approach to optimize cancer management in older adults. We conducted a cost-utility analysis alongside the 5C randomized controlled trial to compare GA and management (GAM) plus usual care (UC) against UC alone in older adults with cancer. METHODS The economic evaluation, conducted from societal and health care payer perspectives, used a 12-month time horizon. The Canadian 5C study randomly assigned patients to receive GAM or UC. Quality-adjusted life-years (QALYs) were measured using the EuroQol five dimension-5L questionnaire and health care utilization using cost diaries and chart reviews. We evaluated the incremental net monetary benefit (INMB) for the full sample and preselected subgroups. RESULTS A total of 350 patients were included, of whom 173 received GAM and 177 UC. At 12 months, the average QALYs per patient were 0.728 and 0.751 for GAM and UC, respectively (ΔQALY, -0.023 [95% CI, -0.076 to 0.028]). Considering a societal perspective, the total average costs (in 2021 Canadian dollars) per patient were $46,739 and $45,177 for GAM and UC, respectively (ΔCost, $1,563 [95% CI, -$6,583 to $10,403]). At a cost-effectiveness threshold of $50,000/QALY, GAM was not cost-effective compared with UC (INMB, -$2,713 [95% CI, -$11,767 to $5,801]). The INMB was positive ($2,984 [95% CI, -$7,050 to $14,179]; probability of being cost-effective, 72%) for patients treated with curative intent, but remained negative for patients treated with palliative intent (INMB, -$9,909 [95% CI, -$24,436 to $4,153]). Findings were similar considering a health care payer perspective. CONCLUSION To our knowledge, this is the first cost-utility analysis of GAM in cancer. GAM was cost-effective for patients with cancer treated with curative but not with palliative intent. The study provides further considerations for future adoption of GAM in practice.
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Affiliation(s)
- Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Department, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shabbir M.H. Alibhai
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Shant T. Yeretzian
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Mohammed R. Anwar
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Bianca McLean
- Department of Medicine, Yale New Haven Hospital, New Haven, CT
| | - Fay Strohschein
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
- Cancer Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - George Tomlinson
- Biostatistics Department, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Aria Wills
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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Atkins P, Tomlinson G, Feig DS. The presence of polycystic ovary syndrome increases the risk of maternal but not neonatal complications in women with type 2 diabetes in pregnancy. Diabetes Metab Res Rev 2024; 40:e3713. [PMID: 37679943 DOI: 10.1002/dmrr.3713] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/09/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
AIMS Our aims were, in the setting of type 2 diabetes mellitus (T2DM) in pregnancy, to investigate the association of polycystic ovary syndrome (PCOS) with perinatal outcomes and to examine whether treatment with metformin had a differential effect in those with and without PCOS. MATERIALS AND METHODS We performed a retrospective cohort study using the metformin in women with type 2 diabetes in pregnancy (MiTy) trial data. We examined differences in maternal and neonatal outcomes among MiTy participants with and without PCOS using linear and logistic regression to adjust for potential confounders. We additionally examined the relative difference in the effect of metformin treatment on pregnancy outcomes among MiTy participants with PCOS versus those without PCOS. RESULTS Among women with T2DM in pregnancy, PCOS was significantly associated with higher excess gestational weight gain (unadjusted 12.0 vs. 11.4 kg, adjusted mean difference 2.1 kg [0.3, 3.9], p = 0.021) and higher total insulin dose at 34-36 weeks (unadjusted 172 vs. 124 units per day, adjusted mean difference 44 units [15, 73], p = 0.004), but no difference was seen in neonatal outcomes. Unlike the non-PCOS subgroup, metformin treatment versus placebo in the PCOS subgroup was associated with an increase in extremely large-for-gestational-age infants (28.6 vs. 14.0%, p = 0.008 for interaction) and an increase in worsened pre-existing maternal hypertension (16.7 vs. 4.5%, p = 0.046 for interaction). CONCLUSIONS Clinicians should be alerted to the potential for high insulin requirements and excess weight gain in pregnant patients with T2DM and comorbid PCOS. Moreover, metformin may not be as beneficial in this population as previously understood.
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Affiliation(s)
- Paul Atkins
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
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Kamso MM, Pardo JP, Whittle SL, Buchbinder R, Wells G, Glennon V, Tugwell P, Deardon R, Sajobi T, Tomlinson G, Elliott J, Kelly SE, Hazlewood GS. Crowd-sourcing and automation facilitated the identification and classification of randomized controlled trials in a living review. J Clin Epidemiol 2023; 164:1-8. [PMID: 37865299 DOI: 10.1016/j.jclinepi.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/05/2023] [Accepted: 10/14/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVES To evaluate an approach using automation and crowdsourcing to identify and classify randomized controlled trials (RCTs) for rheumatoid arthritis (RA) in a living systematic review (LSR). METHODS Records from a database search for RCTs in RA were screened first by machine learning and Cochrane Crowd to exclude non-RCTs, then by trainee reviewers using a Population, Intervention, Comparison, and Outcome (PICO) annotator platform to assess eligibility and classify the trial to the appropriate review. Disagreements were resolved by experts using a custom online tool. We evaluated the efficiency gains, sensitivity, accuracy, and interrater agreement (kappa scores) between reviewers. RESULTS From 42,452 records, machine learning and Cochrane Crowd excluded 28,777 (68%), trainee reviewers excluded 4,529 (11%), and experts excluded 7,200 (17%). The 1,946 records eligible for our LSR represented 220 RCTs and included 148/149 (99.3%) of known eligible trials from prior reviews. Although excluded from our LSRs, 6,420 records were classified as other RCTs in RA to inform future reviews. False negative rates among trainees were highest for the RCT domain (12%), although only 1.1% of these were for the primary record. Kappa scores for two reviewers ranged from moderate to substantial agreement (0.40-0.69). CONCLUSION A screening approach combining machine learning, crowdsourcing, and trainee participation substantially reduced the screening burden for expert reviewers and was highly sensitive.
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Affiliation(s)
- Mohammed Mujaab Kamso
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| | - Jordi Pardo Pardo
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Samuel L Whittle
- Department Rheumatology, The Queen Elizabeth Hospital, Adelaide, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - George Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Vanessa Glennon
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Bruyere Research institute, Ottawa, Canada
| | - Rob Deardon
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Mathematics & Statistics, Faculty of Science, University of Calgary, Calgary, Canada
| | - Tolulope Sajobi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - George Tomlinson
- Department of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jesse Elliott
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Shannon E Kelly
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Glen S Hazlewood
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Shum S, Moreno Garijo J, Tomlinson G, Rodrigues J, Greyling G, Shafiepour D, McRae K, Slinger P. A Clinical Comparison of 2 Bronchial Blockers Versus Double-Lumen Tubes for One-Lung Ventilation. J Cardiothorac Vasc Anesth 2023; 37:2577-2583. [PMID: 37684137 DOI: 10.1053/j.jvca.2023.08.125] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVES To compare the quality of lung collapse, time, and number of attempts required to achieve lung isolation, and incidence of intraoperative malpositioning between the EZ blocker (EZB), Fuji Uniblocker (UB), and the left-sided double lumen tube (DLT). DESIGN Prospective, randomized clinical trial. SETTING Single tertiary-level, university-affiliated hospital. PARTICIPANTS Eighty-nine patients undergoing elective open thoracotomies or video-assisted thoracoscopic surgery. INTERVENTIONS The 89 patients were randomized to receive a DLT, UB, or EZB for one-lung ventilation. MEASUREMENTS AND MAIN RESULTS The quality of lung collapse at the time of pleural opening and 10 and 20 minutes thereafter were assessed by the surgeon using the Lung Collapse Score (LCS; 0 = no lung collapse to 10 = best lung collapse). The time and number of attempts required to achieve lung isolation and the number of repositions required during surgery were measured. Tracheobronchial tree measurements were performed by radiologists from preoperative computed tomography imaging. The surgeon remained blinded to the type of device used. Twenty-nine patients were randomized to the DLT group and 30 patients to each of the EZB and UB groups. The LCSs among the groups at pleural opening and 10 minutes after pleural opening were not significantly different (p = 0.34 and p = 0.08, respectively). However, at 20 minutes after the pleural opening, the LCSs were significantly different among groups (p = 0.02), with median scores being significantly lower for DLT (9 [IQR 8-9]) than for EZB (9 [IQR 9-10]; p = 0.04) and UB (9.5 [IQR 9-10]; p = 0.02). Lung isolation was achieved fastest in the DLT group (p < 0.01). The frequency of difficult placement did not significantly differ among groups, although it occurred most frequently in UB (n = 7; 23.3%). Intraoperative repositioning also occurred most often with the UB (n = 15; 50.0%). The EZB had the greatest number of cases requiring >2 repositions (n = 4, 13.3%). There were no differences between preoperative airway measurements and time to isolation or incidence of intraoperative repositioning among the groups. CONCLUSIONS The LCS was comparable among the 3 devices until 20 minutes after pleural opening, when better scores were obtained in the bronchial blocker groups. Lung isolation was achieved fastest with the DLT. The EZB had the highest incidence of cases requiring >2 intraoperative repositions, mostly occurring in R-sided surgery. For L-sided surgery, the EZB performed equally to the UB. This suggests that using the EZB for R-sided video-assisted thoracoscopic surgery may be suboptimal. Preoperative airway dimensions did not correlate with time to achieve isolation or incidence of intraoperative malpositioning.
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Affiliation(s)
- Serena Shum
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Jacobo Moreno Garijo
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada; Department of Anesthesia and Pain Management, Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - George Tomlinson
- Biostatistics Research Unit, Toronto General Hospital, Toronto, Canada
| | - Jonathan Rodrigues
- Department of Medical Imaging, Toronto General Hospital, Toronto, Canada
| | - Gerhard Greyling
- Department of Medical Imaging, Toronto General Hospital, Toronto, Canada
| | | | - Karen McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Peter Slinger
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
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Wind K, Poland B, HakemZadeh F, Jackson S, Tomlinson G, Jadad A. Using self-reported health as a social determinants of health outcome: a scoping review of reviews. Health Promot Int 2023; 38:daad165. [PMID: 38041807 DOI: 10.1093/heapro/daad165] [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: 12/04/2023] Open
Abstract
Reducing disease prevalence rather than promoting health has long been the objective of significant population health initiatives, such as the social determinants of health (SDH) framework. However, empirical evidence suggests that people with diagnosed diseases often answer the self-reported health (SRH) question positively. In pursuit of a better proxy to understand, measure and improve health, this scoping review of reviews examines the potential of SRH to be used as an outcome of interest in population health policies. Following PRISMA-ScR guidelines, it synthesizes findings from 77 review papers (published until 11 May 2022) and reports a robust association between SDH and SRH. It also investigates inconsistencies within and between reviews to reveal how variation in population health can be explained by studying the impact of contextual factors, such as cultural, social, economic and political elements, on structural determinants such as socioeconomic situation, gender and ethnicity. These insights provide informed hypotheses for deeper explorations of the role of SDH in improving SRH. The review detects several gaps in the literature. Notably, more evidence syntheses are required, in general, on the pathway from contextual elements to population SRH and, in particular, on the social determinants of adolescents' SRH. This study reports a disease-oriented mindset in collecting, analysing and reporting SRH across the included reviews. Future studies should utilize the capability of SRH in interconnecting social, psychological and biological dimensions of health to actualize its full potential as a central public health measure.
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Affiliation(s)
- Keiwan Wind
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4M4, Canada
| | - Blake Poland
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Farimah HakemZadeh
- Faculty of Liberal Arts and Professional Studies, School of Human Resources Management, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada
| | - Suzanne Jackson
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Alejandro Jadad
- Centre for Digital Therapeutics, R. Fraser Elliott Building, 4th Floor, 190 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
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18
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Tomlinson G, Al-Khafaji A, Conrad SA, Factora FNF, Foster DM, Galphin C, Gunnerson KJ, Khan S, Kohli-Seth R, McCarthy P, Meena NK, Pearl RG, Rachoin JS, Rains R, Seneff M, Tidswell M, Walker PM, Kellum JA. Bayesian methods: a potential path forward for sepsis trials. Crit Care 2023; 27:432. [PMID: 37940985 PMCID: PMC10634134 DOI: 10.1186/s13054-023-04717-x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Given the success of recent platform trials for COVID-19, Bayesian statistical methods have become an option for complex, heterogenous syndromes like sepsis. However, study design will require careful consideration of how statistical power varies using Bayesian methods across different choices for how historical data are incorporated through a prior distribution and how the analysis is ultimately conducted. Our objective with the current analysis is to assess how different uses of historical data through a prior distribution, and type of analysis influence results of a proposed trial that will be analyzed using Bayesian statistical methods. METHODS We conducted a simulation study incorporating historical data from a published multicenter, randomized clinical trial in the US and Canada of polymyxin B hemadsorption for treatment of endotoxemic septic shock. Historical data come from a 179-patient subgroup of the previous trial of adult critically ill patients with septic shock, multiple organ failure and an endotoxin activity of 0.60-0.89. The trial intervention consisted of two polymyxin B hemoadsorption treatments (2 h each) completed within 24 h of enrollment. RESULTS In our simulations for a new trial of 150 patients, a range of hypothetical results were observed. Across a range of baseline risks and treatment effects and four ways of including historical data, we demonstrate an increase in power with the use of clinically defensible incorporation of historical data. In one possible trial result, for example, with an observed reduction in risk of mortality from 44 to 37%, the probability of benefit is 96% with a fixed weight of 75% on prior data and 90% with a commensurate (adaptive-weighting) prior; the same data give an 80% probability of benefit if historical data are ignored. CONCLUSIONS Using Bayesian methods and a biologically justifiable use of historical data in a prior distribution yields a study design with higher power than a conventional design that ignores relevant historical data. Bayesian methods may be a viable option for trials in critical care medicine where beneficial treatments have been elusive.
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Affiliation(s)
- George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health, Shreveport, LA, USA
| | - Faith N F Factora
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Claude Galphin
- Southeast Renal Research Institute, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Sobia Khan
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul McCarthy
- West Virginia University, Heart & Vascular Institute, Morgantown, WV, USA
| | - Nikhil K Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ronald Rains
- Pulmonary Associates, Univ of Colorado Health-Memorial Hospital, Colorado Springs, CO, USA
| | - Michael Seneff
- Department of Anesthesia and Critical Care, George Washington University Hospital, Washington, DC, USA
| | - Mark Tidswell
- Pulmonary and Critical Care Division, Baystate Medical Center, Springfield, MA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
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19
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Song C, Dhaliwal S, Bapat P, Scarr D, Bakhsh A, Budhram D, Verhoeff NJ, Weisman A, Fralick M, Ivers NM, Cherney DZI, Tomlinson G, Lovblom LE, Mumford D, Perkins BA. Point-of-Care Capillary Blood Ketone Measurements and the Prediction of Future Ketoacidosis Risk in Type 1 Diabetes. Diabetes Care 2023; 46:1973-1977. [PMID: 37616393 DOI: 10.2337/dc23-0840] [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] [Received: 05/09/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Rather than during illness while diabetic ketoacidosis (DKA) is developing, we aimed to determine if levels of routine point-of-care capillary blood ketones could predict future DKA. RESEARCH DESIGN AND METHODS We examined previously collected data from placebo-assigned participants in an adjunct-to-insulin medication trial program that included measurement of fasted capillary blood ketone levels twice per week in a 2-month baseline period. The outcome was 6- to 12-month trial-adjudicated DKA. RESULTS DKA events occurred in 12 of 484 participants at a median of 105 (interquartile range 43, 199) days. Maximum ketone levels were higher in patient cases compared with in control patients (0.8 [0.6, 1.2] vs. 0.3 [0.2, 0.7] mmol/L; P = 0.002), with a nonparametric area under the receiver operating characteristic curve of 0.77 (95% CI 0.66-0.88). Ketone levels ≥0.8 mmol/L had a sensitivity of 64%, a specificity of 78%, and positive and negative likelihood ratios of 2.9 and 0.5, respectively. CONCLUSIONS This proof of concept that routine capillary ketone surveillance can identify individuals at high risk of future DKA implies a role for future technologies including continuous ketone monitoring.
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Affiliation(s)
- Cimon Song
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sharon Dhaliwal
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Priya Bapat
- Division of General Internal Medicine, Department of Medicine, University Health Network and Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Abdulmohsen Bakhsh
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Kidney & Pancreas Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Dalton Budhram
- Division of General Internal Medicine, Department of Medicine, University Health Network and Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha J Verhoeff
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michael Fralick
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University Health Network and Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | - Noah M Ivers
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Doug Mumford
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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20
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Dale NM, Ashir GM, Maryah LB, Shepherd S, Tomlinson G, Briend A, Zlotkin S, Parshuram CS. Evaluating the Validity of the Responses to Illness Severity Quantification Score to Discriminate Illness Severity and Level of Care Transitions in Hospitalized Children with Severe Acute Malnutrition. J Pediatr 2023; 262:113609. [PMID: 37419241 DOI: 10.1016/j.jpeds.2023.113609] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/25/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization. STUDY DESIGN A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions. RESULTS Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91). CONCLUSIONS The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.
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Affiliation(s)
- Nancy M Dale
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Garba Mohammed Ashir
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Lawan Bukar Maryah
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - André Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland; Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Christopher S Parshuram
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
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21
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Clairman H, Dover S, Tomlinson G, Beebe D, Cameron B, Laxer RM, Levy D, Narang I, Paetkau S, Schneider R, Spiegel L, Stephens S, Stinson J, Tse S, Weiss S, Whitney K, Feldman BM. Lengthening sleep reduces pain in childhood arthritis: a crossover randomised controlled trial. RMD Open 2023; 9:e003352. [PMID: 37914178 PMCID: PMC10619109 DOI: 10.1136/rmdopen-2023-003352] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVES Juvenile idiopathic arthritis (JIA) is a common chronic childhood disease and chronic pain is a debilitating feature. A strong link has been shown between poor sleep and pain in JIA. However, the causal direction is unknown. This study's aim was to determine if, in adolescents with JIA, a recommended healthful sleep duration leads to reductions in pain when compared with the restricted sleep (RS) duration that is commonly seen. METHODS Patients with JIA (12-18 years old; pain score of ≥1 on a visual analogue scale) participated in a randomised, crossover sleep manipulation protocol. The 3-week protocol comprised a baseline week (BL), a week with healthy sleep duration (HSD; 9.5 hours in bed/night) and a RS week (RS; 6.5 hours in bed/night). After BL, participants were randomly assigned to either HSD or RS, and then crossed over to the other condition. Pain was self-assessed using the iCanCope with Pain app. We used Bayesian hierarchical models to estimate the effect of sleep duration on pain. RESULTS Participants (n=31; mean age=15.0±1.8 years) averaged 1.4 (95% credible interval (CrI) 1.2-1.6) more hours of sleep per night during HSD relative to RS. Compared with RS, HSD resulted in a favourable effect on pain scores (OR 0.61, 95% CrI 0.39-0.95). CONCLUSION It is possible to have adolescents with childhood arthritis get a healthier sleep duration, and this longer sleep results in reduced pain. These findings complement prior correlational studies and confirm a causal relationship between reduced sleep duration and increased pain. TRIAL REGISTRATION NUMBER NCT04133662.
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Affiliation(s)
- Hayyah Clairman
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Saunya Dover
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - George Tomlinson
- Division of Clinical Decision Making & Health Care, Toronto General Research Institute, Toronto, Ontario, Canada
| | - Dean Beebe
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bonnie Cameron
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald M Laxer
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deborah Levy
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Indra Narang
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan Paetkau
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rayfel Schneider
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lynn Spiegel
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samantha Stephens
- Neurosciences & Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Jennifer Stinson
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Shirley Tse
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shelly Weiss
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kristi Whitney
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian M Feldman
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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22
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Zeitouny S, Cheung DC, Bremner KE, Pataky RE, Pequeno P, Matelski J, Peacock S, Del Giudice ME, Lapointe-Shaw L, Tomlinson G, Mendlowitz AB, Mulder C, Tsui TCO, Perlis N, Walker JD, Sander B, Wong WWL, Krahn MD, Kulkarni GS. The impact of the early COVID-19 pandemic on healthcare system resource use and costs in two provinces in Canada: An interrupted time series analysis. PLoS One 2023; 18:e0290646. [PMID: 37682823 PMCID: PMC10490868 DOI: 10.1371/journal.pone.0290646] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/11/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION The aim of our study was to assess the initial impact of COVID-19 on total publicly-funded direct healthcare costs and health services use in two Canadian provinces, Ontario and British Columbia (BC). METHODS This retrospective repeated cross-sectional study used population-based administrative datasets, linked within each province, from January 1, 2018 to December 27, 2020. Interrupted time series analysis was used to estimate changes in the level and trends of weekly resource use and costs, with March 16-22, 2020 as the first pandemic week. Also, in each week of 2020, we identified cases with their first positive SARS-CoV-2 test and estimated their healthcare costs until death or December 27, 2020. RESULTS The resources with the largest level declines (95% confidence interval) in use in the first pandemic week compared to the previous week were physician services [Ontario: -43% (-49%,-37%); BC: -24% (-30%,-19%) (both p<0.001)] and emergency department visits [Ontario: -41% (-47%,-35%); BC: -29% (-35%,-23%) (both p<0.001)]. Hospital admissions declined by 27% (-32%,-23%) in Ontario and 21% (-26%,-16%) in BC (both p<0.001). Resource use subsequently rose but did not return to pre-pandemic levels. Only home care and dialysis clinic visits did not significantly decrease compared to pre-pandemic. Costs for COVID-19 cases represented 1.3% and 0.7% of total direct healthcare costs in 2020 in Ontario and BC, respectively. CONCLUSIONS Reduced utilization of healthcare services in the overall population outweighed utilization by COVID-19 patients in 2020. Meeting the needs of all patients across all services is essential to maintain resilient healthcare systems.
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Affiliation(s)
- Seraphine Zeitouny
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Douglas C. Cheung
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- Divisions of Urology and Surgical Oncology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karen E. Bremner
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Reka E. Pataky
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Stuart Peacock
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - M. Elisabeth Del Giudice
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of General Internal Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Andrew B. Mendlowitz
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Carol Mulder
- Chiefs of Ontario, Toronto, Ontario, Canada
- Queen’s University, Kingston, Ontario, Canada
| | - Teresa C. O. Tsui
- ICES, Toronto, Ontario, Canada
- Child Health and Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Canadian Centre for Applied Research in Cancer Control, Ontario Health-Cancer Care Ontario, Toronto, Ontario, Canada
| | - Nathan Perlis
- Divisions of Urology and Surgical Oncology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, Sprott Department of Surgery, University Health Network, Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jennifer D. Walker
- ICES, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Beate Sander
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - William W. L. Wong
- ICES, Toronto, Ontario, Canada
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - Murray D. Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Girish S. Kulkarni
- Divisions of Urology and Surgical Oncology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of Urology, Sprott Department of Surgery, University Health Network, Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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23
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Sage AT, Donahoe LL, Shamandy AA, Mousavi SH, Chao BT, Zhou X, Valero J, Balachandran S, Ali A, Martinu T, Tomlinson G, Del Sorbo L, Yeung JC, Liu M, Cypel M, Wang B, Keshavjee S. A machine-learning approach to human ex vivo lung perfusion predicts transplantation outcomes and promotes organ utilization. Nat Commun 2023; 14:4810. [PMID: 37558674 PMCID: PMC10412608 DOI: 10.1038/s41467-023-40468-7] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Ex vivo lung perfusion (EVLP) is a data-intensive platform used for the assessment of isolated lungs outside the body for transplantation; however, the integration of artificial intelligence to rapidly interpret the large constellation of clinical data generated during ex vivo assessment remains an unmet need. We developed a machine-learning model, termed InsighTx, to predict post-transplant outcomes using n = 725 EVLP cases. InsighTx model AUROC (area under the receiver operating characteristic curve) was 79 ± 3%, 75 ± 4%, and 85 ± 3% in training and independent test datasets, respectively. Excellent performance was observed in predicting unsuitable lungs for transplantation (AUROC: 90 ± 4%) and transplants with good outcomes (AUROC: 80 ± 4%). In a retrospective and blinded implementation study by EVLP specialists at our institution, InsighTx increased the likelihood of transplanting suitable donor lungs [odds ratio=13; 95% CI:4-45] and decreased the likelihood of transplanting unsuitable donor lungs [odds ratio=0.4; 95%CI:0.16-0.98]. Herein, we provide strong rationale for the adoption of machine-learning algorithms to optimize EVLP assessments and show that InsighTx could potentially lead to a safe increase in transplantation rates.
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Affiliation(s)
- Andrew T Sage
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Laura L Donahoe
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alaa A Shamandy
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - S Hossein Mousavi
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Bonnie T Chao
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Xuanzi Zhou
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Jerome Valero
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Sharaniyaa Balachandran
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Aadil Ali
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Medical and Surgical Intensive Care Unit, University Health Network, Toronto, ON, Canada
| | - Jonathan C Yeung
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Bo Wang
- Department of Computer Science, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Vector Institute, Toronto, ON, Canada.
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Chow R, Mathews JJ, Cheng EY, Lo S, Wong J, Alam S, Hannon B, Rodin G, Nissim R, Hales S, Kavalieratos D, Quinn KL, Tomlinson G, Zimmermann C. Interventions to improve outcomes for caregivers of patients with advanced cancer: a meta-analysis. J Natl Cancer Inst 2023; 115:896-908. [PMID: 37279594 PMCID: PMC10407714 DOI: 10.1093/jnci/djad075] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/04/2023] [Accepted: 05/01/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Family caregivers of patients with advanced cancer often have poor quality of life (QOL) and mental health. We examined the effectiveness of interventions offering support for caregivers of patients with advanced cancer on caregiver QOL and mental health outcomes. METHODS We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, and Cumulative Index to Nursing and Allied Health Literature databases from inception through June 2021. Eligible studies reported on randomized controlled trials for adult caregivers of adult patients with advanced cancer. Meta-analysis was conducted for primary outcomes of QOL, physical well-being, mental well-being, anxiety, and depression, from baseline to follow-up of 1-3 months; secondary endpoints were these outcomes at 4-6 months and additional caregiver burden, self-efficacy, family functioning, and bereavement outcomes. Random effects models were used to generate summary standardized mean differences (SMD). RESULTS Of 12 193 references identified, 56 articles reporting on 49 trials involving 8554 caregivers were eligible for analysis; 16 (33%) targeted caregivers, 19 (39%) patient-caregiver dyads, and 14 (29%) patients and their families. At 1- to 3-month follow-up, interventions had a statistically significant effect on overall QOL (SMD = 0.24, 95% confidence interval [CI] = 0.10 to 0.39); I2 = 52.0%), mental well-being (SMD = 0.14, 95% CI = 0.02 to 0.25; I2 = 0.0%), anxiety (SMD = 0.27, 95% CI = 0.06 to 0.49; I2 = 74.0%), and depression (SMD = 0.34, 95% CI = 0.16 to 0.52; I2 = 64.4) compared with standard care. In narrative synthesis, interventions demonstrated improvements in caregiver self-efficacy and grief. CONCLUSIONS Interventions targeting caregivers, dyads, or patients and families led to improvements in caregiver QOL and mental health. These data support the routine provision of interventions to improve well-being in caregivers of patients with advanced cancer.
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Affiliation(s)
- Ronald Chow
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jean J Mathews
- Division of Palliative Medicine, Department of Medicine and Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Emily YiQin Cheng
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Samantha Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Joanne Wong
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sorayya Alam
- Palliative Medicine, Sobell House, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Kieran L Quinn
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of General Internal Medicine and Palliative Care, Department of Medicine, Sinai Health System, Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - George Tomlinson
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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25
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Foroutan F, Rayner DG, Ross HJ, Ehler T, Srivastava A, Shin S, Malik A, Benipal H, Yu C, Alexander Lau TH, Lee JG, Rocha R, Austin PC, Levy D, Ho JE, McMurray JJV, Zannad F, Tomlinson G, Spertus JA, Lee DS. Global Comparison of Readmission Rates for Patients With Heart Failure. J Am Coll Cardiol 2023; 82:430-444. [PMID: 37495280 DOI: 10.1016/j.jacc.2023.05.040] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/09/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Heart failure (HF) readmission rates are low in some jurisdictions. However, international comparisons are lacking and could serve as a foundation for identifying regional patient management strategies that could be shared to improve outcomes. OBJECTIVES This study sought to summarize 30-day and 1-year all-cause readmission and mortality rates of hospitalized HF patients across countries and to explore potential differences in rates globally. METHODS We performed a systematic review and meta-analysis using MEDLINE, Embase, and CENTRAL for observational reports on hospitalized adult HF patients at risk for readmission or mortality published between January 2010 and March 2021. We conducted a meta-analysis of proportions using a random-effects model, and sources of heterogeneity were evaluated with meta-regression. RESULTS In total, 24 papers reporting on 30-day and 23 papers on 1-year readmission were included. Of the 1.5 million individuals at risk, 13.2% (95% CI: 10.5%-16.1%) were readmitted within 30 days and 35.7% (95% CI: 27.1%-44.9%) within 1 year. A total of 33 papers reported on 30-day and 45 papers on 1-year mortality. Of the 1.5 million individuals hospitalized for HF, 7.6% (95% CI: 6.1%-9.3%) died within 30 days and 23.3% (95% CI: 20.8%-25.9%) died within 1 year. Substantial variation in risk across countries was unexplained by countries' gross domestic product, proportion of gross domestic product spent on health care, and Gini coefficient. CONCLUSIONS Globally, hospitalized HF patients exhibit high rates of readmission and mortality, and the variability in readmission rates was not explained by health care expenditure, risk of mortality, or comorbidities.
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Affiliation(s)
- Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Daniel G Rayner
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Tamara Ehler
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Ananya Srivastava
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sheojung Shin
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Abdullah Malik
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harsukh Benipal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clarissa Yu
- Faculty of Arts and Science, University of Toronto, Toronto, Ontario, Canada
| | | | - Joshua G Lee
- Faculty of Medical Sciences, Western University, London, Ontario, Canada
| | | | - Peter C Austin
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Daniel Levy
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts, USA
| | - Jennifer E Ho
- Cardiovascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Faiez Zannad
- Clinical Investigation Centre (Inserm-CHU) and Academic Hospital (CHU), Nancy, France
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - John A Spertus
- St Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - Douglas S Lee
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto, Ontario, Canada; ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.
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26
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Sockalingam S, Leung SE, Ma C, Tomlinson G, Hawa R, Wnuk S, Jackson T, Urbach D, Okrainec A, Brown J, Sandre D, Cassin SE. Efficacy of Telephone-Based Cognitive Behavioral Therapy for Weight Loss, Disordered Eating, and Psychological Distress After Bariatric Surgery: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2327099. [PMID: 37535357 PMCID: PMC10401302 DOI: 10.1001/jamanetworkopen.2023.27099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
Importance Weight regain after bariatric surgery is associated with recurrence of obesity-related medical comorbidities and deterioration in quality of life. Developing efficacious psychosocial interventions that target risk factors, prevent weight regain, and improve mental health is imperative. Objective To determine the efficacy of a telephone-based cognitive behavioral therapy (tele-CBT) intervention at 1 year after bariatric surgery in improving weight loss, disordered eating, and psychological distress. Design, Setting, and Participants This multisite randomized clinical trial was conducted at 3 hospital-based bariatric surgery programs, with recruitment between February 2018 and December 2021. Eligibility for participation was assessed among 314 adults at 1 year after bariatric surgery who were fluent in English and had access to a telephone and the internet. Patients with active suicidal ideation or poorly controlled severe psychiatric illness were excluded. Primary and secondary outcome measures were assessed at baseline (1 year after surgery), after the intervention (approximately 15 months after surgery), and at 3-month follow-up (approximately 18 months after surgery). Data were analyzed from January to February 2023. Interventions The tele-CBT intervention consisted of 6 weekly 1-hour sessions and a seventh booster session 1 month later. The control group received standard postoperative bariatric care. Main Outcomes and Measures The primary outcome was postoperative percentage total weight loss. Secondary outcomes were disordered eating (Binge Eating Scale [BES] and Emotional Eating Scale [EES]) and psychological distress (Patient Health Questionnaire-9 item scale [PHQ-9] and Generalized Anxiety Disorder-7 item scale [GAD-7]). The hypotheses and data-analytic plan were developed prior to data collection. Results Among 306 patients 1 year after bariatric surgery (255 females [83.3%]; mean [SD] age, 47.55 [9.98] years), there were 152 patients in the tele-CBT group and 154 patients in the control group. The group by time interaction for percentage total weight loss was not significant (F1,160.61 = 2.09; P = .15). However, there were significant interactions for mean BES (F2,527.32 = 18.73; P < .001), EES total (F2,530.67 = 10.83; P < .001), PHQ-9 (F2,529.93 = 17.74; P < .001), and GAD-7 (F2,535.16 = 15.29; P < .001) scores between the tele-CBT group and control group across all times. Conclusions and Relevance This study found that tele-CBT delivered at 1 year after surgery resulted in no change in short-term weight outcomes but improved disordered eating and psychological distress. The impact of these psychosocial improvements on longer-term weight outcomes is currently being examined as part of this longitudinal multisite randomized clinical trial. Trial Registration ClinicalTrials.gov Identifier: NCT03315247.
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Affiliation(s)
- Sanjeev Sockalingam
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Samantha E Leung
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
| | - Clement Ma
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Raed Hawa
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Susan Wnuk
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Timothy Jackson
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
- Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Urbach
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Women's College Hospital, Toronto, Canada
| | - Allan Okrainec
- Bariatric Surgery Program, University Health Network, Toronto, Ontario, Canada
| | - Jennifer Brown
- Ottawa Hospital Bariatric Centre of Excellence, Ottawa, Ontario, Canada
| | - Daniella Sandre
- Ottawa Hospital Bariatric Centre of Excellence, Ottawa, Ontario, Canada
| | - Stephanie E Cassin
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
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Brignardello-Petersen R, Tomlinson G, Florez I, Rind DM, Chu D, Morgan R, Mustafa RA, Schünemann H, Guyatt GH. Grading of recommendations assessment, development, and evaluation concept article 5: addressing intransitivity in a network meta-analysis. J Clin Epidemiol 2023; 160:151-159. [PMID: 37348573 DOI: 10.1016/j.jclinepi.2023.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 04/18/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES This article describes considerations for addressing intransitivity when assessing the certainty of the evidence from network meta-analysis (NMA) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Intransitivity is induced by effect modification, that is, when the magnitude of the effect between an intervention and outcome differs depending on the level of another factor. STUDY DESIGN AND SETTING To develop this GRADE concept paper, the lead authors conducted iterative discussions, computer simulations, and presentations to the GRADE project group and at GRADE working group meetings. The GRADE Working Group formally approved the article in July 2022. RESULTS NMA authors can have a higher or a lower threshold to rate down the certainty of the evidence due to intransitivity, which depends on the extent of their concerns regarding the trustworthiness of indirect comparisons, and their view of the relative problems with rating down excessively or insufficiently. NMA authors should consider three main factors when addressing intransitivity: the credibility of effect modification, the strength of the effect modification, and the distribution of effect modifiers across the direct comparisons. To avoid double counting limitations of the evidence, authors should consider the relationship between intransitivity and other GRADE domains. CONCLUSION NMA authors face theoretic and pragmatic challenges and in most situations need to assess intransitivity without the availability of empirical data. Thus, explicitness regarding perspective is crucial.
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Affiliation(s)
- Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence and Impact, McMaster University, HSC-2C, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada.
| | - George Tomlinson
- Department of Medicine, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Ivan Florez
- Department of Pediatrics, University of Antioquia, Calle 67 # 53-108, Medellin 050001, Colombia; School of Rehabilitation Science, McMaster University, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada
| | - David M Rind
- Institute for Clinical and Economic Review, 14 Beacon Street, Boston, MA 02108, USA
| | - Derek Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, HSC-2C, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada
| | - Rebecca Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, HSC-2C, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada
| | - Reem A Mustafa
- Deparment of Internal Medicine and Department of Population Health, Univeristy of Kansas Medical Center, MS3002, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Holger Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, HSC-2C, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada; Department of Medicine, McMaster University, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milano 20090, Italy
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, HSC-2C, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada; Department of Medicine, McMaster University, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada
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28
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Dianti J, Morris IS, Urner M, Schmidt M, Tomlinson G, Amato MBP, Blanch L, Rubenfeld G, Goligher EC. Linking Acute Physiology to Outcomes in the ICU: Challenges and Solutions for Research. Am J Respir Crit Care Med 2023; 207:1441-1450. [PMID: 36705985 DOI: 10.1164/rccm.202206-1216ci] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
ICU clinicians rely on bedside physiological measurements to inform many routine clinical decisions. Because deranged physiology is usually associated with poor clinical outcomes, it is tempting to hypothesize that manipulating and intervening on physiological parameters might improve outcomes for patients. However, testing these hypotheses through mathematical models of the relationship between physiology and outcomes presents a number of important methodological challenges. These models reflect the theories of the researcher and can therefore be heavily influenced by one's assumptions and background beliefs. Model building must therefore be approached with great care and forethought, because failure to consider relevant sources of measurement error, confounding, coupling, and time dependency or failure to assess the direction of causality for associations of interest before modeling may give rise to spurious results. This paper outlines the main challenges in analyzing and interpreting these models and offers potential solutions to address these challenges.
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Affiliation(s)
- Jose Dianti
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
| | - Idunn S Morris
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesiology and Pain Medicine
| | | | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Lluis Blanch
- Critical Care Center, Institut d'Investigacio i Innovacio Parc Taulí I3PT-CERCA, Parc Taulí Hospital Universitari, Universitat Autonoma de Barcelona, Sabadell, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Universitat Autonoma de Barcelona, Parc Taulí 1, Sabadell, Spain
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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29
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Ali A, Hoetzenecker K, Luis Campo-Cañaveral de la Cruz J, Schwarz S, Barturen MG, Tomlinson G, Yeung J, Donahoe L, Yasufuku K, Pierre A, de Perrot M, Waddell TK, Keshavjee S, Cypel M. Extension of Cold Static Donor Lung Preservation at 10°C. NEJM Evid 2023; 2:EVIDoa2300008. [PMID: 38320127 DOI: 10.1056/evidoa2300008] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Cold Static Donor Lung Preservation at 10°CDonor lungs for transplantation are currently stored on ice and transplanted as rapidly as possible. In an advance that may ease transplant logistics, Ali et al. report that prolonged storage at 10°C may lead to equivalent outcomes.
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Affiliation(s)
- Aadil Ali
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | | | | | | | | | - George Tomlinson
- Department of Medicine, University Health Network/Mount Sinai Hospital, Toronto
| | - Jonathan Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Laura Donahoe
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Andrew Pierre
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Marc de Perrot
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Thomas K Waddell
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto
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30
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Amitai I, Roos K, Rashedi I, Jiang Y, Mangoff K, Klein G, Forward N, Stewart D, Laneuville P, Bence-Bruckler I, Mangel J, Tomlinson G, Berinstein NL. PD-L1 expression predicts efficacy in the phase II SPiReL trial with MVP-S, pembrolizumab, and low-dose CPA in R/R DLBCL. Eur J Haematol 2023. [PMID: 37157906 DOI: 10.1111/ejh.13982] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Patients with relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) have limited treatment options. METHODS R/R DLBCL patients, who were mostly ineligible for ASCT due to age or comorbidities, were treated with maveropepimut-S (MVP-S, previously DPX-Survivac) a survivin directed T cell educating therapy, pembrolizumab, and intermittent low-dose cyclophosphamide. FINDINGS We identified, using univariate analysis, a subset of patients with enhanced ORR, PFS and DOR. Patients with baseline CD20+/PD-L1 expression had an ORR of 46% (6/13) and the disease control rate was 10/13 (77%). The PFS and OS of the positive CD20+/PD-L1 patients were 7.1 months and 17.4 months, whereas in the intent-to-treat (ITT) population of 25 enrolled patients, the ORR was 28% (7/25), median PFS and OS were 4.2 months and 10.1 months respectively. A total of 6/7 clinical responders occurred in CD20+/PD-L1 patients. The regimen was well-tolerated, requiring only minor dose modifications and one discontinuation. Grade 1 or 2 injection site reactions occurred in 14/25, (56%). Statistically significant associations were also seen between PFS and; injection site reactions; and ELISpot response to survivin peptides, both identifying the mechanistic importance of specific immune responses to survivin. INTERPRETATION This immunotherapy combination was found to be active and safe in this clinically challenging patient population.
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Affiliation(s)
- Irina Amitai
- Sunnybrook Health Sciences Centre, Toronto, Canada
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Kim Roos
- Sunnybrook Research Institute, Toronto, Canada
| | | | - Yidi Jiang
- Sunnybrook Research Institute, Toronto, Canada
| | | | - Gail Klein
- Sunnybrook Research Institute, Toronto, Canada
| | | | | | | | | | - Joy Mangel
- London Health Sciences Centre, London, Canada
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Timilshina N, Finelli A, Tomlinson G, Sander B, Alibhai SMH. Applying Quality Indicators to Examine Quality of Care During Active Surveillance in Low-Risk Prostate Cancer: A Population-Based Study. J Natl Compr Canc Netw 2023; 21:465-472.e9. [PMID: 37156486 DOI: 10.6004/jnccn.2022.7256] [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: 06/29/2022] [Accepted: 12/21/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the population level. METHODS QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diagnosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diagnosis, and physician volume. RESULTS The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59-71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%-100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant variations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65-74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1-2 patients with AS and 95.8% for those with ≥6 patients with AS annually). CONCLUSIONS This study establishes a foundation for quality-of-care assessments and monitoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician volume and Qis related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.
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Affiliation(s)
- Narhari Timilshina
- 1Department of Medicine, University Health Network, Toronto, Ontario, Canada
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Antonio Finelli
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- 3Division of Urology and Surgical Oncology, University Health Network, Toronto, Ontario, Canada
| | - George Tomlinson
- 1Department of Medicine, University Health Network, Toronto, Ontario, Canada
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Beate Sander
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- 4The Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada
- 5Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- 6Institute of Clinical Research Services, Toronto, Ontario, Canada
- 7Public Health Ontario, Toronto, Ontario, Canada
| | - Shabbir M H Alibhai
- 1Department of Medicine, University Health Network, Toronto, Ontario, Canada
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Vettese E, Sherani F, King AA, Yu L, Aftandilian C, Baggott C, Agarwal V, Nagasubramanian R, Kelly KM, Freyer DR, Orgel E, Bradfield SM, Kyono W, Roth M, Klesges LM, Beauchemin M, Grimes A, Tomlinson G, Dupuis LL, Sung L. Symptom management care pathway adaptation process and specific adaptation decisions. BMC Cancer 2023; 23:350. [PMID: 37069510 PMCID: PMC10108500 DOI: 10.1186/s12885-023-10835-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/11/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND There is substantial heterogeneity in symptom management provided to pediatric patients with cancer. The primary objective was to describe the adaptation process and specific adaptation decisions related to symptom management care pathways based on clinical practice guidelines. The secondary objective evaluated if institutional factors were associated with adaptation decisions. METHODS Fourteen previously developed symptom management care pathway templates were reviewed by an institutional adaptation team composed of two clinicians at each of 10 institutions. They worked through each statement for all care pathway templates sequentially. The institutional adaptation team made the decision to adopt, adapt or reject each statement, resulting in institution-specific symptom management care pathway drafts. Institutional adaption teams distributed the 14 care pathway drafts to their respective teams; their feedback led to care pathway modifications. RESULTS Initial care pathway adaptation decision making was completed over a median of 4.2 (interquartile range 2.0-5.3) weeks per institution. Across all institutions and among 1350 statements, 551 (40.8%) were adopted, 657 (48.7%) were adapted, 86 (6.4%) were rejected and 56 (4.1%) were no longer applicable because of a previous decision. Most commonly, the reason for rejection was not agreeing with the statement (70/86, 81.4%). Institutional-level factors were not significantly associated with statement rejection. CONCLUSIONS Acceptability of the 14 care pathways was evident by most statements being adopted or adapted. The adaptation process was accomplished over a relatively short timeframe. Future work should focus on evaluation of care pathway compliance and determination of the impact of care pathway-consistent care on patient outcomes. TRIAL REGISTRATION clinicaltrials.gov, NCT04614662. Registered 04/11/2020, https://clinicaltrials.gov/ct2/show/NCT04614662?term=NCT04614662&draw=2&rank=1 .
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Affiliation(s)
- Emily Vettese
- Program in Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
| | - Farha Sherani
- Driscoll Children's Hospital, Cancer and Blood Disorders Center, 3533 S. Alameda Street, Corpus Christi, TX, 78411, US
- Texas A&M University, College Station, TX, US
| | - Allison A King
- Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO, 63110, US
| | - Lolie Yu
- Louisiana State University Health Sciences Center/Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA
| | | | | | - Vibhuti Agarwal
- Nemours Children's Hospital of The Nemours Foundation, 6535 Nemours Parkway, Orlando, FL, 32827, US
| | | | - Kara M Kelly
- Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 665 Elm St., Buffalo, NY, 14203, US
| | - David R Freyer
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, US
| | - Etan Orgel
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, US
| | - Scott M Bradfield
- Nemours Children's Health, 807 Children's Way, Jacksonville, FL, 32207, US
| | - Wade Kyono
- Kapi'olani Medical Center for Women & Children, 1319 Punahou Street, Honolulu, Hawai'i, 96826, US
| | - Michael Roth
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, US
| | - Lisa M Klesges
- Division of Public Health Sciences, Washington University School of Medicine, 600 So Taylor Ave, St. Louis, MO, 63110, US
| | - Melissa Beauchemin
- Columbia University School of Nursing/Herbert Irving Cancer Center, 560 West 168th Street, New York, NY, 10032, USA
| | - Allison Grimes
- Pediatric Hematology Oncology, University of Texas Health, The Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, US
| | - George Tomlinson
- Department of Medicine, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - L Lee Dupuis
- Program in Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pharmacy, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Lillian Sung
- Program in Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Olupot-Olupot P, Tomlinson G, Williams TN, Tshilolo L, Santos B, Smart LR, McElhinney K, Howard TA, Aygun B, Stuber SE, Lane A, Latham TS, Ware RE. Hydroxyurea treatment is associated with lower malaria incidence in children with sickle cell anemia in sub-Saharan Africa. Blood 2023; 141:1402-1410. [PMID: 36375125 PMCID: PMC10273078 DOI: 10.1182/blood.2022017051] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/05/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
Realizing Effectiveness Across Continents with Hydroxyurea (REACH, NCT01966731) provides hydroxyurea at maximum tolerated dose (MTD) for children with sickle cell anemia (SCA) in sub-Saharan Africa. Beyond reducing SCA-related clinical events, documented treatment benefits include ∼50% reduction in malaria incidence. To identify associations and propose mechanisms by which hydroxyurea could be associated with lower malaria rates, infections were recorded across all clinical sites (Angola, Democratic Republic of Congo, Kenya, and Uganda). Hazard ratios (HR) with 95% confidence intervals (CIs) for baseline demographics, and time-varying laboratory and clinical parameters were estimated in a modified Cox gap-time model for repeated events. Over 3387 patient-years of hydroxyurea treatment, 717 clinical malaria episodes occurred in 336 of 606 study participants; over half were confirmed by blood smear and/or rapid diagnostic testing with 97.8% Plasmodium falciparum. In univariate analysis limited to 4 confirmed infections per child, malaria risk was significantly associated with absolute neutrophil count (ANC), splenomegaly, hemoglobin, and achieving MTD; age, malaria season, MTD dose, fetal hemoglobin, α-thalassemia, and glucose-6-phosphate dehydrogenase deficiency had no effect. In multivariable regression of confirmed infections, ANC was significant (HR, 1.37 per doubled value; 95% CI, 1.10-1.70; P = .0052), and ANC values <3.0 × 109/L were associated with lower malaria incidence. Compared with nonpalpable spleen, 1- to 4-cm splenomegaly also was associated with higher malaria risk (HR, 2.01; 95% CI, 1.41-2.85; P = .0001). Hydroxyurea at MTD is associated with lower malaria incidence in SCA through incompletely defined mechanisms, but treatment-associated mild myelosuppression with ANC <3.0 × 109/L is salutary. Splenomegaly is an unexplained risk factor for malaria infections among children with SCA in Africa.
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Affiliation(s)
- Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale, Uganda
- Mbale Regional Referral and Teaching Hospital/Busitema University, Mbale, Uganda
| | - George Tomlinson
- Department of Medicine, University Health Network and Mt Sinai Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Thomas N. Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Léon Tshilolo
- Institut de Recherche Biomédicale in CEFA/Centre Hospitalier Monkole, Kinshasa, Democratic Republic of Congo
| | | | - Luke R. Smart
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
- Global Health Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kathryn McElhinney
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
| | - Thad A. Howard
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
| | - Banu Aygun
- Cohen Children’s Medical Center, New Hyde Park, NY
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Susan E. Stuber
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
- Global Health Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adam Lane
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Teresa S. Latham
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
| | - Russell E. Ware
- Division of Hematology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
- Global Health Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Feng G, Parthipan M, Breunis H, Puts M, Emmenegger U, Timilshina N, Hansen AR, Finelli A, Krzyzanowska MK, Matthew A, Clarke H, Mina DS, Soto-Perez-de-Celis E, Tomlinson G, Alibhai SMH. Feasibility and acceptability of remote symptom monitoring (RSM) in older adults during treatment for metastatic prostate cancer. J Geriatr Oncol 2023; 14:101469. [PMID: 36917921 DOI: 10.1016/j.jgo.2023.101469] [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: 11/21/2022] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Emerging data support multiple benefits of remote symptom monitoring (RSM) during chemotherapy to improve outcomes. However, these studies have not focused on older adults and do not include treatments beyond chemotherapy. Although chemotherapy, androgen receptor axis-targeted therapies (ARATs), and radium-223 prolong survival, toxicities are substantial and increased in older adults with metastatic prostate cancer (mPC). We aimed to assess RSM feasibility among older adults receiving life-prolonging mPC treatments. MATERIALS AND METHODS Older adults aged 65+ starting chemotherapy, an ARAT, or radium-223 for mPC were enrolled in a multicentre prospective cohort study. As part of the RSM package, participants completed the Edmonton Symptom Assessment Scale (ESAS) daily and detailed questionnaires assessing mood, anxiety, fatigue, insomnia, and pain weekly online or by phone throughout one treatment cycle (3-4 weeks). Alerts were sent to the clinical oncology team for severe symptoms (ESAS ≥7). Participants also completed an end of study questionnaire that assessed study burden and satisfaction. Descriptive statistics were used to determine recruitment and retention rates, participant response rates to daily and weekly questionnaires, clinician responses to alerts, and participant satisfaction rates. An inductive descriptive approach was used to categorize open-ended responses about study benefits, challenges, and recommendations into relevant themes. RESULTS Ninety males were included (mean age 77 years, 48% ARAT, 38% chemotherapy, and 14% radium-223). Approximately 38% of patients preferred phone-based RSM. Patients provided RSM responses in 1216 out of 1311 daily questionnaires (93%). Over 93% of participants were satisfied (36%), very satisfied (43%), or extremely satisfied (16%) with RSM, although daily reporting was reported by several (8%) as burdensome. Nearly 45% of patients reported severe symptoms during RSM. Most symptom alerts sent to the oncology care team were acknowledged (97%) and 53% led to follow-ups with a nurse or physician for additional care. DISCUSSION RSM is feasible and acceptable to older adults with mPC, but accommodation needs to be made for phone-based RSM. The optimal frequency and duration of RSM also needs to be established.
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Affiliation(s)
- Gregory Feng
- Department of Medicine, University Health Network, Toronto, Canada.
| | | | | | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Toronto, Canada.
| | | | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Antonio Finelli
- Division of Urology, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Monika K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Andrew Matthew
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Hance Clarke
- Department of Anesthesia, Toronto General Hospital, Toronto, Canada.
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada.
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico.
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Canada.
| | - Shabbir M H Alibhai
- Department of Medicine, University Health Network, Toronto, Canada; Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.
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Abrahamyan L, Tomlinson G, Callum J, Carcone S, Grewal D, Bartoszko J, Krahn M, Karkouti K. Cost-effectiveness of Fibrinogen Concentrate vs Cryoprecipitate for Treating Acquired Hypofibrinogenemia in Bleeding Adult Cardiac Surgical Patients. JAMA Surg 2023; 158:245-253. [PMID: 36598773 PMCID: PMC9857805 DOI: 10.1001/jamasurg.2022.6818] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Excessive bleeding requiring fibrinogen replacement is a serious complication of cardiac surgery. However, the relative cost-effectiveness of the 2 available therapies-fibrinogen concentrate and cryoprecipitate-is unknown. Objective To determine cost-effectiveness of fibrinogen concentrate vs cryoprecipitate for managing active bleeding in adult patients who underwent cardiac surgery. Design, Setting, and Participants A within-trial economic evaluation of the Fibrinogen Replenishment in Surgery (FIBERS) randomized clinical trial (February 2017 to November 2018) that took place at 4 hospitals based in Ontario, Canada, hospitals examined all in-hospital resource utilization costs and allogeneic blood product (ABP) transfusion costs incurred within 28 days of surgery. Participants included a subset of 495 adult patients from the FIBERS trial who underwent cardiac surgery and developed active bleeding and acquired hypofibrinogenemia requiring fibrinogen replacement. Interventions Fibrinogen concentrate (4 g per dose) or cryoprecipitate (10 units per dose) randomized (1:1) up to 24 hours postcardiopulmonary bypass. Main Outcomes and Measures Effectiveness outcomes included number of ABPs administered within 24 hours and 7 days of cardiopulmonary bypass. ABP transfusion (7-day) and in-hospital resource utilization (28-day) costs were evaluated and a multivariable net benefit regression model built for the full sample and predefined subgroups. Results Patient level costs for 495 patients were evaluated (mean [SD] age 59.2 [15.4] years and 69.3% male.) Consistent with FIBERS, ABP transfusions and adverse events were similar in both treatment groups. Median (IQR) total 7-day ABP cost was CAD $2280 (US dollars [USD] $1697) (CAD $930 [USD $692]-CAD $4970 [USD $3701]) in the fibrinogen concentrate group and CAD $2770 (USD $1690) (IQR, CAD $1140 [USD $849]-CAD $5000 [USD $3723]) in the cryoprecipitate group. Median (interquartile range) total 28-day cost was CAD $38 180 (USD $28 431) $(IQR, CAD $26 350 [USD $19 622]-CAD $65 080 [USD $48 463]) in the fibrinogen concentrate group and CAD $38 790 (USD $28 886) (IQR, CAD $26 180 [USD $19 495]-CAD $70 380 [USD $52 409]) in the cryoprecipitate group. After exclusion of patients who were critically ill before surgery (11%) due to substantial variability in costs, the incremental net benefit of fibrinogen concentrate vs cryoprecipitate was positive (probability of being cost-effective 86% and 97% at $0 and CAD $2000 (USD $1489) willingness-to-pay, respectively). Net benefit was highly uncertain for nonelective and patients with critical illness. Conclusions and Relevance Fibrinogen concentrate is cost-effective when compared with cryoprecipitate in most bleeding adult patients who underwent cardiac surgery with acquired hypofibrinogenemia requiring fibrinogen replacement. The generalizability of these findings outside the Canadian health system needs to be verified.
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Affiliation(s)
- Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Steven Carcone
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Deep Grewal
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, Ontario, Canada
| | - Justyna Bartoszko
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Murray Krahn
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Keyvan Karkouti
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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Feig DS, Sanchez JJ, Murphy KE, Asztalos E, Zinman B, Simmons D, Haqq AM, Fantus IG, Lipscombe L, Armson A, Barrett J, Donovan L, Karanicolas P, Tobin S, Mangoff K, Klein G, Jiang Y, Tomlinson G, Hamilton J. Outcomes in children of women with type 2 diabetes exposed to metformin versus placebo during pregnancy (MiTy Kids): a 24-month follow-up of the MiTy randomised controlled trial. Lancet Diabetes Endocrinol 2023; 11:191-202. [PMID: 36746160 DOI: 10.1016/s2213-8587(23)00004-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Metformin is increasingly being used during pregnancy, with potentially adverse long-term effects on children. We aimed to examine adiposity in children of women with type 2 diabetes from the Metformin in Women with Type 2 Diabetes in Pregnancy (MiTy) trial, with and without in-utero exposure to metformin, up to 24 months of age. METHODS MiTy Kids is a follow-up study that included infants of women who participated in the MiTy randomised controlled trial, receiving either oral 1000 mg metformin twice daily or placebo. Caregivers and researchers remained masked to the type of medication (metformin or placebo) mothers received during their pregnancy. Anthropometric measurements, including weight, height, and skinfold thicknesses, were taken at 3, 6, 12, 18, and 24 months. At 24 months, linear regression was used to compare the BMI Z score and sum of skinfolds in the metformin versus placebo groups, adjusted for confounders. Fractional polynomials were used to assess growth trajectories. This study is registered with ClinicalTrials.gov, NCT01832181. FINDINGS Of the 465 eligible children, 283 (61%) were included from 19 centres in Canada and Australia. At 24 months, there was no difference between groups in mean BMI Z score (0·84 [SD 1·52] with metformin vs 0·91 [1·38] with placebo; mean difference 0·07 [95% CI -0·31 to 0·45], p=0·72) or mean sum of skinfolds (23·0 mm [5·2] vs 23·8 mm [5·4]; mean difference 0·8 mm [-0·7 to 2·3], p=0·31). Metformin was not a predictor of BMI Z score at 24 months of age (mean difference -0·01 [95% CI -0·42 to 0·37], p=0·92). There was no overall difference in BMI trajectory but, in males, trajectories were significantly different by treatment (p=0·048); BMI in the metformin group was higher between 6 and 24 months. Children of women with type 2 diabetes were approximately 1 SD heavier than the WHO reference population. INTERPRETATION Anthropometrics were similar in children exposed and those not exposed to metformin in utero; hence, overall, data are reassuring with regard to the use of metformin during pregnancy in women with type 2 diabetes and the long-term health of their children. FUNDING Canadian Institute for Health Research.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada.
| | | | - Kellie E Murphy
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - Elizabeth Asztalos
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bernard Zinman
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - David Simmons
- Department of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Andrea M Haqq
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - I George Fantus
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada; Department of Medicine and Research Institute, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Lorraine Lipscombe
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Anthony Armson
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, NS, Canada
| | - Jon Barrett
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lois Donovan
- Department of Medicine and Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Paul Karanicolas
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | - Gail Klein
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Yidi Jiang
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Jill Hamilton
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Timilshina N, Alibhai SMH, Tomlinson G, Sander B, Cheung DC, Finelli A. Long-term Outcomes Following Active Surveillance of Low-grade Prostate Cancer: A Population-based Study Using a Landmark Approach. J Urol 2023; 209:540-548. [PMID: 36475730 DOI: 10.1097/ju.0000000000003097] [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: 07/01/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Active surveillance is widely used to manage low-risk prostate cancer, but population-level long-term outcomes are limited. Our objective was to determine long-term population-level oncological outcomes in active surveillance patients. A secondary objective examined the active surveillance discontinuation rate. MATERIALS AND METHODS In this retrospective, population-based study using linked administrative databases from Ontario, Canada, we identified low-grade prostate cancer patients managed with active surveillance or initial treatment between 2002-2014. The 10- and 15-year metastasis-free survival, overall survival, and cancer-specific survival were compared between active surveillance and initial treatment. A landmark of 24 months was selected for the primary analysis. Long-term outcomes were examined using multivariable proportional hazards models and a propensity-based approach. RESULTS The cohort consisted of 21,282 low-grade prostate cancer patients with a median follow-up of 9.8 years. At 10-year follow-up the survival rate of remaining on active surveillance was 39%, metastasis-free survival was 94.2%, overall survival 88.7%, and cancer-specific survival 98.1%. In adjusted models active surveillance was associated with higher risk of metastasis (HR 1.34, 95%CI 1.15-1.57), overall mortality (HR 1.12, 95%CI 1.01-1.24), and prostate cancer-specific mortality (HR 1.66, 95%CI 1.15-2.39) compared to initial treatment. Survival analysis using 7,525 propensity-matched pairs was consistent with the primary analysis for metastasis-free survival, overall survival and cancer-specific survival. CONCLUSIONS In this large population-based study of long-term outcomes in men with low-grade prostate cancer, active surveillance is associated with excellent long-term metastasis-free survival and overall survival. However, long-term cancer-specific survival was slightly inferior (1% worse at 10 years with active surveillance), and this must be balanced against known harms of overtreatment.
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Affiliation(s)
- N Timilshina
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - S M H Alibhai
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - G Tomlinson
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - B Sander
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - D C Cheung
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
- Division of Urology and Surgical Oncology, University Health Network, Toronto, Ontario, Canada
| | - A Finelli
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
- Division of Urology and Surgical Oncology, University Health Network, Toronto, Ontario, Canada
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Kim VS, Yang H, Timilshina N, Breunis H, Emmenegger U, Gregg R, Hansen AR, Tomlinson G, Alibhai SMH. The role of frailty in modifying physical function and quality of life over time in older men with metastatic castration-resistant prostate cancer. J Geriatr Oncol 2023; 14:101417. [PMID: 36682218 DOI: 10.1016/j.jgo.2022.12.005] [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: 07/19/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION As treatment options for metastatic castration-resistant prostate cancer (mCRPC) expand and its patient population ages, consideration of frailty is increasingly relevant. Using a novel frailty index (FI) and two common frailty screening tools, we examined quality of life (QoL) and physical function (PF) in frail versus non-frail men receiving treatment for mCRPC. MATERIALS AND METHODS Men aged 65+ starting docetaxel chemotherapy, abiraterone, or enzalutamide for mCRPC were enrolled in a multicenter prospective cohort study. QoL, fatigue, pain, and mood were measured with the Functional Assessment of Cancer Therapy-General scale, the Edmonton Symptom Assessment System tiredness and pain subscales, and the Patient Health Questionnaire-9. PF was evaluated with grip strength, four-meter gait speed, five times Sit-to-Stand Test, and instrumental activities of daily living. Frailty was determined using the Vulnerable Elders Survey (VES-13), the Geriatric 8 (G8), and an FI constructed from 36 variables spanning laboratory abnormalities, geriatric syndromes, functional status, social support, as well as emotional, cognitive, and physical deficits. We categorized patients as non-frail (FI ≤ 0.2, VES < 3, G8 > 14), pre-frail (FI > 0.20, ≤0.35), or frail (FI > 0.35, VES ≥ 3, G8 ≤ 14); assessed correlation between the three tools; and performed linear mixed-effects regression analyses to examine longitudinal differences in outcomes (0, 3, 6 months) by frailty status. A sensitivity analysis with worst-case imputation was conducted to explore attrition. RESULTS We enrolled 175 men (mean age 74.9 years) starting docetaxel (n = 71), abiraterone (n = 37), or enzalutamide (n = 67). Our FI demonstrated moderate correlation with the VES-13 (r = 0.607, p < 0.001) and the G8 (r = -0.520, p < 0.001). Baseline FI score was associated with worse QoL (p < 0.001), fatigue (p < 0.001), pain (p < 0.001), mood (p < 0.001), PF (p < 0.001), and higher attrition (p < 0.01). Over time, most outcomes remained stable, although pain improved, on average, regardless of frailty status (p = 0.007), while fatigue (p = 0.045) and mood (p = 0.015) improved in frail patients alone. DISCUSSION Among older men receiving care for mCRPC, frailty may be associated with worse baseline QoL and PF, but over time, frail patients may experience largely similar trends in QoL and PF as their non-frail counterparts. Further study with larger sample size and longer follow-up may help elucidate how best to incorporate frailty into treatment decision-making for mCRPC.
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Affiliation(s)
- Valerie S Kim
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Helen Yang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | | | - Urban Emmenegger
- Department of Medicine, University of Toronto, Toronto, Canada; Division of Medical Oncology, Odette Cancer Centre, Toronto, Canada
| | - Richard Gregg
- Division of Medical Oncology, Queen's University, Kingston, Canada
| | - Aaron R Hansen
- Department of Medicine, University of Toronto, Toronto, Canada; Division of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Shabbir M H Alibhai
- Department of Medicine, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
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Beliavsky A, Johnston B, Li Q, Tomlinson G, Kaul R, Granton J. Secondary infections in critically ill patients with viral pneumonia due to COVID-19 and influenza: a historical cohort study. Can J Anaesth 2023; 70:374-383. [PMID: 36918454 PMCID: PMC10013978 DOI: 10.1007/s12630-022-02376-0] [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: 11/26/2021] [Revised: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 03/15/2023] Open
Abstract
PURPOSE To compare the incidence and nature of secondary infections (SI) between critically ill patients with viral pneumonia due to COVID-19 and seasonal influenza and explore the association between SI and clinical outcomes. METHODS We conducted a historical cohort study of patients admitted to the intensive care unit (ICU) at two tertiary care centers during the first wave of the COVID-19 pandemic and patients admitted with influenza during the 2018-2019 season. The primary outcome was the rate of SI. Secondary outcomes included rates of ICU and in-hospital mortality, organ-support-dependent disease, and length of ICU and hospital stay. RESULTS Secondary infections developed in 55% of 95 COVID-19 patients and 51% of 47 influenza patients (unadjusted odds ratio [OR], 1.16; 95% confidence interval [CI], 0.57 to 2.33). After adjusting for baseline differences between cohorts, there were no significant differences between the COVID-19 cohort and the influenza cohort (adjusted OR, 1.00; 95% CI, 0.41 to 2.44). COVID-19 patients with SI had longer ICU and hospital stays and duration of mechanical ventilation. The SI incidence was higher in COVID-19 patients treated with steroids than in those not treated with steroids (15/20, 75% vs 37/75, 49%). CONCLUSION Secondary infections were common among critically ill patients with viral pneumonia including COVID-19. We found no difference in the incidence of SI between COVID-19 and influenza in our cohort study, but SI in patients with COVID-19 were associated with worse clinical outcomes and increased healthcare resource use. The small cohort size precludes any causal inferences but may provide a basis for future research.
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Affiliation(s)
- Alina Beliavsky
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
| | - Barry Johnston
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Sinai Health System, Toronto, ON, Canada
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
- Division of Respirology, University of Toronto, University Health Network, Toronto, ON, Canada
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Dixon PR, Shapiro J, Tomlinson G, Cottrell J, Lui JT, Falk L, Chen JM. Health State Utility Values Associated with Cochlear Implants in Adults: A Systematic Review and Network Meta-Analysis. Ear Hear 2023; 44:244-253. [PMID: 36303282 DOI: 10.1097/aud.0000000000001287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The cost-effectiveness of bilateral cochlear implants in adults remains uncertain despite established clinical benefits. In cost-effectiveness studies, benefit is often measured by change in health state utility value (HSUV), a single number summary of health-related quality of life anchored at 0 (state of being dead) and 1 (perfect health). Small differences in bilateral cochlear implant HSUV change conclusions of published models, and invalid estimates can therefore mislead policy and funding decisions. As such, we aimed to review and synthesize published HSUV estimates associated with cochlear implants. DESIGN We included observational or experimental studies reporting HSUV for adult patients (age ≥18 years) with at least moderate-profound sensorineural hearing loss in both ears who received unilateral or bilateral cochlear implants. We searched MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases up to May 1, 2021. Study and participant characteristics and HSUV outcomes were extracted. Narrative synthesis is reported for all studies. A Bayesian network meta-analysis was conducted to generate pooled estimates for the mean difference in HSUV for three comparisons: (1) unilateral cochlear implant versus preimplant, (2) bilateral cochlear implants versus preimplant, (3) bilateral versus unilateral cochlear implants. Our principal measure was pooled mean difference in HSUV. RESULTS Thirty-six studies reporting unique patient cohorts were identified. Health Utilities Index, 3 (HUI-3) was the most common HSUV elicitation method. HSUV from 19 preimplant mean estimates (1402 patients), 19 unilateral cochlear implant mean estimates (1701 patients), and 5 bilateral cochlear implants mean estimates (83 patients) were pooled to estimate mean differences in HUI-3 HSUV by network meta-analysis. Compared with preimplant, a unilateral cochlear implant was associated with a mean change in HSUV of +0.17 (95% credible interval [CrI] +0.12 to +0.23) and bilateral cochlear implants were associated with a mean change of +0.25 (95% CrI +0.12 to +0.37). No significant difference in HSUV was detected for bilateral compared with unilateral cochlear implants (+0.08 [95% CrI -0.06 to +0.21]). Overall study quality was moderate. CONCLUSIONS The findings of this review and network meta-analysis comprise the best-available resource for parameterization of cost-utility models of cochlear implantation in adults and highlight the need to critically evaluate the validity of available HSUV instruments for bilateral cochlear implant populations.Protocol registration: PROSPERO (CRD42018091838).
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Affiliation(s)
- Peter R Dixon
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, San Diego, California
| | - Justin Shapiro
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto
| | - George Tomlinson
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - Justin Cottrell
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Canada
| | - Justin T Lui
- Section of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Lindsey Falk
- Evidence, Development and Standards, Health Quality Ontario
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Joseph M Chen
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
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Yarnell CJ, Angriman F, Ferreyro BL, Liu K, De Grooth HJ, Burry L, Munshi L, Mehta S, Celi L, Elbers P, Thoral P, Brochard L, Wunsch H, Fowler RA, Sung L, Tomlinson G. Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts. Crit Care 2023; 27:67. [PMID: 36814287 PMCID: PMC9944781 DOI: 10.1186/s13054-023-04307-x] [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] [Received: 12/02/2022] [Accepted: 01/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. METHODS This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008-2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003-2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. RESULTS We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). CONCLUSION Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.
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Affiliation(s)
- Christopher J. Yarnell
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Federico Angriman
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Bruno L. Ferreyro
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Kuan Liu
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Harm Jan De Grooth
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lisa Burry
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.492573.e0000 0004 6477 6457Department of Pharmacy and Medicine, Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
| | - Laveena Munshi
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Sangeeta Mehta
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Leo Celi
- grid.116068.80000 0001 2341 2786Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142 USA ,grid.239395.70000 0000 9011 8547Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215 USA ,grid.38142.3c000000041936754XDepartment of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Paul Elbers
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick Thoral
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laurent Brochard
- grid.415502.7Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hannah Wunsch
- grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert A. Fowler
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, Toronto, Canada ,grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lillian Sung
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.42327.300000 0004 0473 9646Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - George Tomlinson
- grid.231844.80000 0004 0474 0428Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
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Yarnell CJ, Johnson A, Dam T, Jonkman A, Liu K, Wunsch H, Brochard L, Celi LA, De Grooth HJ, Elbers P, Mehta S, Munshi L, Fowler RA, Sung L, Tomlinson G. Do Thresholds for Invasive Ventilation in Hypoxemic Respiratory Failure Exist? A Cohort Study. Am J Respir Crit Care Med 2023; 207:271-282. [PMID: 36150166 DOI: 10.1164/rccm.202206-1092oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rationale: Invasive ventilation is a significant event for patients with respiratory failure. Physiologic thresholds standardize the use of invasive ventilation in clinical trials, but it is unknown whether thresholds prompt invasive ventilation in clinical practice. Objectives: To measure, in patients with hypoxemic respiratory failure, the probability of invasive ventilation within 3 hours after meeting physiologic thresholds. Methods: We studied patients admitted to intensive care receiving FiO2 of 0.4 or more via nonrebreather mask, noninvasive positive pressure ventilation, or high-flow nasal cannula, using data from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019) and the Amsterdam University Medical Centers Database (AmsterdamUMCdb) (2003-2016). We evaluated 17 thresholds, including the ratio of arterial to inspired oxygen, the ratio of saturation to inspired oxygen ratio, composite scores, and criteria from randomized trials. We report the probability of invasive ventilation within 3 hours of meeting each threshold and its association with covariates using odds ratios (ORs) and 95% credible intervals (CrIs). Measurements and Main Results: We studied 4,726 patients (3,365 from MIMIC, 1,361 from AmsterdamUMCdb). Invasive ventilation occurred in 28% (1,320). In MIMIC, the highest probability of invasive ventilation within 3 hours of meeting a threshold was 20%, after meeting prespecified neurologic or respiratory criteria while on vasopressors, and 19%, after a ratio of arterial to inspired oxygen of <80 mm Hg. In AmsterdamUMCdb, the highest probability was 34%, after vasopressor initiation, and 25%, after a ratio of saturation to inspired oxygen of <90. The probability after meeting the threshold from randomized trials was 9% (MIMIC) and 13% (AmsterdamUMCdb). In MIMIC, a race/ethnicity of Black (OR, 0.75; 95% CrI, 0.57-0.96) or Asian (OR, 0.6; 95% CrI, 0.35-0.95) compared with White was associated with decreased probability of invasive ventilation after meeting a threshold. Conclusions: The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was low and associated with patient race/ethnicity.
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Affiliation(s)
- Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Division of Respirology
| | | | - Tariq Dam
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation, and
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts; and
| | - Harm-Jan De Grooth
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Paul Elbers
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lillian Sung
- Institute of Health Policy, Management and Evaluation, and.,Division of Haematology/Oncology
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
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Badrov MB, Keir DA, Tomlinson G, Notarius CF, Millar PJ, Kimmerly DS, Shoemaker JK, Keys E, Floras JS. Normal and excessive muscle sympathetic nerve activity in heart failure: implications for future trials of therapeutic autonomic modulation. Eur J Heart Fail 2023; 25:201-210. [PMID: 36459000 DOI: 10.1002/ejhf.2749] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
AIMS Patients with sympathetic excess are those most likely to benefit from novel interventions targeting the autonomic nervous system. To inform such personalized therapy, we identified determinants of augmented muscle sympathetic nerve activity (MSNA) in heart failure, versus healthy controls. METHODS AND RESULTS We compared data acquired in 177 conventionally-treated, stable non-diabetic patients in sinus rhythm, aged 18-79 years (149 males; 28 females; left ventricular ejection fraction [LVEF] 25 ± 11% [mean ± standard deviation]; range 5-60%), and, concurrently, under similar conditions, in 658 healthy, normotensive volunteers (398 males; aged 18-81 years). In heart failure, MSNA ranged between 7 and 90 bursts·min-1 , proportionate to heart rate (p < 0.0001) and body mass index (BMI) (p = 0.03), but was unrelated to age, blood pressure, or drug therapy. Mean MSNA, adjusted for age, sex, BMI, and heart rate, was greater in heart failure (+14.2 bursts·min-1 ; 95% confidence interval [CI] 12.1-16.3; p < 0.0001), but lower in women (-5.0 bursts·min-1 ; 95% CI 3.4-6.6; p < 0.0001). With spline modeling, LVEF accounted for 9.8% of MSNA variance; MSNA related inversely to LVEF below an inflection point of ∼21% (p < 0.006), but not above. Burst incidence was greater in ischaemic than dilated cardiomyopathy (p = 0.01), and patients with sleep apnoea (p = 0.03). Burst frequency correlated inversely with stroke volume (p < 0.001), cardiac output (p < 0.001), and peak oxygen consumption (p = 0.002), and directly with norepinephrine (p < 0.0001) and peripheral resistance (p < 0.001). CONCLUSION Burst frequency and incidence exceeded normative values in only ∼53% and ∼33% of patients. Such diversity encourages selective deployment of sympatho-modulatory therapies. Clinical characteristics can highlight individuals who may benefit from future personalized interventions targeting pathological sympathetic activation.
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Affiliation(s)
- Mark B Badrov
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Daniel A Keir
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- School of Kinesiology, Western University, London, Ontario, Canada
| | - George Tomlinson
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Catherine F Notarius
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Philip J Millar
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Department of Human Health and Nutritional Science, University of Guelph, Guelph, Ontario, Canada
| | - Derek S Kimmerly
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Division of Kinesiology, School of Health and Performance, Dalhousie University, Halifax, Nova Scotia, Canada
| | - J Kevin Shoemaker
- School of Kinesiology, Western University, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Evan Keys
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - John S Floras
- University Health Network and Sinai Health Division of Cardiology, Department of Medicine, University of Toronto and the Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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Abrahamyan L, Doudney F, Tomlinson G, Callum J, Carcone S, Grewal D, Bartoszko J, Krahn M, Karkouti K. Fibrinogen Concentrate vs Cryoprecipitate for Treating Acquired Hypofibrinogenemia in Bleeding Adult Cardiac Surgical Patients: A Within-trial Economic Evaluation of the FIBRES Randomized Controlled Trial. Transfus Med Rev 2023. [DOI: 10.1016/j.tmrv.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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Alibhai SMH, Papadopoulos E, Durbano S, Tomlinson G, Mina DS, Ritvo P, Sabiston CM, Matthew AG, Chiarotto J, Sidani S, Culos-Reed SN. Preference-based versus randomized controlled trial in prostate cancer survivors: Comparison of recruitment, adherence, attrition, and clinical outcomes. Front Oncol 2022; 12:1033229. [PMID: 36578945 PMCID: PMC9791189 DOI: 10.3389/fonc.2022.1033229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/31/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Patients' unwillingness to be randomized to a mode of exercise may partly explain their poor recruitment, adherence, and attrition in randomized controlled trials (RCTs) of exercise in oncology. It is unknown whether a preference-based trial can improve recruitment, adherence, retention, and clinical outcomes compared to a RCT of the same exercise interventions. Objective We assessed the effects of a 2-arm exercise preference trial on adherence and clinical outcomes compared to a similar 2-arm RCT in men with prostate cancer (PC). Methods This was a two-arm preference-based trial of group-based training (GROUP) or home-based training (HOME). PC survivors on androgen deprivation therapy (ADT) who declined randomization to the RCT but chose to participate in a preference trial were recruited in four Canadian centers. All study participants engaged in aerobic and resistance training, 4-5 days weekly for 6 months, aiming for 150 minutes/week of moderate-to-vigorous physical activity. The primary outcomes were changes from baseline to 6 months in fatigue and functional endurance. Secondary outcomes were quality of life, physical fitness, body composition, blood markers, and adherence. Linear mixed models were used to assess the effects of HOME versus GROUP on primary outcomes. In pooled preference and RCT data, the selection effect (i.e., difference between those who were and were not willing to be randomized) and treatment effect (i.e., difference between GROUP and HOME) were estimated using linear regression. Results and conclusion Fifty-four participants (mean [SD] age, 70.2 [8.6] years) were enrolled (GROUP n=17; HOME n=37). Comparable effects on primary and secondary outcomes were observed following GROUP or HOME in the preference-based trial. Adherence was similar between preference and RCT participants. However, attrition was higher in the RCT (50.0% vs. 27.8%, p= 0.04). Compared to GROUP, HOME was more effective in ameliorating fatigue (mean difference: +5.2, 95%CI=1.3 to 9.3 p=0.01) in pooled preference and RCT data. A preference-based trial results in comparable observed effects on clinical outcomes and adherence and lower attrition compared with a RCT of the same exercise interventions in PC survivors on ADT. Given the appeals of preference-based trials to study participants, additional studies are warranted. Clinical trial registration clinicaltrials.gov, identifier (NCT03335631).
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Affiliation(s)
- Shabbir M. H. Alibhai
- Department of Medicine, University Health Network, Toronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada,*Correspondence: Shabbir M. H. Alibhai,
| | | | - Sara Durbano
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Paul Ritvo
- Department of Psychology, School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Catherine M. Sabiston
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Andrew G. Matthew
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - James Chiarotto
- Department of Medicine, Division of Hematology/Oncology, Scarborough Health Network, Scarborough, ON, Canada
| | - Souraya Sidani
- Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, ON, Canada
| | - S. Nicole Culos-Reed
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada,Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Beukelman T, Tomlinson G, Nigrovic PA, Dennos A, Del Gaizo V, Jelinek M, Riordan ME, Schanberg LE, Mohan S, Pfeifer E, Kimura Y. First-line options for systemic juvenile idiopathic arthritis treatment: an observational study of Childhood Arthritis and Rheumatology Research Alliance Consensus Treatment Plans. Pediatr Rheumatol Online J 2022; 20:113. [PMID: 36482434 PMCID: PMC9730566 DOI: 10.1186/s12969-022-00768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/06/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed consensus treatment plans (CTPs) to compare treatment initiation strategies for systemic juvenile idiopathic arthritis (sJIA). First-line options for sJIA treatment (FROST) was a prospective observational study to assess CTP outcomes using the CARRA Registry. METHODS Patients with new-onset sJIA were enrolled if they received initial treatment according to the biologic CTPs (IL-1 or IL-6 inhibitor) or non-biologic CTPs (glucocorticoid (GC) monotherapy or methotrexate). CTPs could be used with or without systemic GC. Primary outcome was achievement of clinical inactive disease (CID) at 9 months without current use of GC. Due to the small numbers of patients in the non-biologic CTPs, no statistical comparisons were made between the CTPs. RESULTS Seventy-three patients were enrolled: 63 (86%) in the biologic CTPs and 10 (14%) in the non-biologic CTPs. CTP choice appeared to be strongly influenced by physician preference. During the first month of follow-up, oral GC use was observed in 54% of biologic CTP patients and 90% of non-biologic CTPs patients. Five (50%) non-biologic CTP patients subsequently received biologics within 4 months of follow-up. Overall, 30/53 (57%) of patients achieved CID at 9 months without current GC use. CONCLUSION Nearly all patients received treatment with biologics during the study period, and 46% of biologic CTP patients did not receive oral GC within the first month of treatment. The majority of patients had favorable short-term clinical outcomes. Increased use of biologics and decreased use of GC may lead to improved outcomes in sJIA.
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Affiliation(s)
- Timothy Beukelman
- University of Alabama at Birmingham, 1601 4th Ave South, CPPN G10, Birmingham, AL, 35233, USA.
| | - George Tomlinson
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Peter A. Nigrovic
- grid.2515.30000 0004 0378 8438Division of Immunology, Boston Children’s Hospital, Boston, MA 02115 USA ,grid.62560.370000 0004 0378 8294Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA 02115 USA
| | - Anne Dennos
- grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Duke University, Durham, NC 27715 USA
| | - Vincent Del Gaizo
- grid.499903.eChildhood Arthritis and Rheumatology Research Alliance, Washington, DC USA
| | - Marian Jelinek
- grid.499903.eChildhood Arthritis and Rheumatology Research Alliance, Washington, DC USA
| | - Mary Ellen Riordan
- grid.429392.70000 0004 6010 5947Joseph M Sanzari Children’s Hospital, Hackensack Meridian School of Medicine, Nutley, NJ 07110 USA
| | - Laura E. Schanberg
- grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Duke University, Durham, NC 27715 USA ,grid.26009.3d0000 0004 1936 7961Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710 USA
| | - Shalini Mohan
- grid.418158.10000 0004 0534 4718Genentech Inc., South San Francisco, CA 94080 USA
| | - Erin Pfeifer
- grid.418158.10000 0004 0534 4718Genentech Inc., South San Francisco, CA 94080 USA
| | - Yukiko Kimura
- grid.429392.70000 0004 6010 5947Joseph M Sanzari Children’s Hospital, Hackensack Meridian School of Medicine, Nutley, NJ 07110 USA
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Dixon PR, Feeny D, Tomlinson G, Cushing SL, Chen JM. Improving the Hearing Status Discrimination of the Health Utilities Index, Mark 3: Design of the Hearing Status Classification System. Otol Neurotol 2022; 43:e1069-e1076. [PMID: 36109145 DOI: 10.1097/mao.0000000000003689] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Redesign the health status classification system of the Health Utilities Index, Mark 3 (HUI-3) "hearing" attribute to improve its discrimination of hearing-impaired health states. STUDY DESIGN Domain and item selection from a previously generated item set guided by a domain and item importance survey, structural independence, and cognitive interviews with patients. SETTING Tertiary referral center. PARTICIPANTS Patients with a range of hearing loss severities, etiologies, and treatment experiences participated in the domain and item importance survey (n = 108) and hour-long cognitive interviews (n = 10). MAIN OUTCOME AND MEASURES Subattributes and levels for the novel Hearing attribute. Domain and item importance was scored on a seven-point Likert scale (1, not at all important; 7, extremely important). RESULTS Mean domain importance was highest for "speech in noise" (6.21; 95% confidence interval, 5.98-6.43) and lowest for "benefits of hearing loss" (3.46; 95% confidence interval, 3.03-3.89). Domains with moderate or greater ( r ≥ 0.5) domain importance Pearson correlation or construct overlap that interfered with structural independence were combined into single subattributes. Iterative adjustments to instructions, items, and phrasing were guided by cognitive interviews to derive the final instrument with seven subattributes: speech, environmental sounds, localization, listening effort, tinnitus, music, and assistive devices. The novel hearing attribute defines 25,920 unique hearing states. CONCLUSION The novel HUI-hearing is part of a comprehensive health utility instrument designed for individuals with hearing loss. Pending derivation of a hearing single attribute utility function and evaluation of measurement properties, our innovative approach could be used to improve health utility measurement for impairments described by any of the other HUI-3 attributes.
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Affiliation(s)
| | - David Feeny
- Department of Economics and Centre for Health Economics and Policy Analysis, McMaster University, and Health Utilities Incorporated, Hamilton
| | | | - Sharon L Cushing
- Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto
| | - Joseph M Chen
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Canada
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Alibhai S, Breunis H, Timilshina N, Yang H, Kim V, Tomlinson G, Emmenegger U. Falls in Older Men During Treatment for Metastatic Castration-Resistant Prostate Cancer (mCRPC). J Geriatr Oncol 2022. [DOI: 10.1016/s1879-4068(22)00275-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yang H, Kim VS, Timilshina N, Breunis H, Emmenegger U, Gregg R, Hansen A, Tomlinson G, Alibhai SM. Impact of treatment on elder-relevant physical function and quality of life outcomes in older adults with metastatic castration-resistant prostate cancer. J Geriatr Oncol 2022; 14:101395. [PMID: 36988103 DOI: 10.1016/j.jgo.2022.10.010] [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] [Received: 07/24/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Understanding physical function (PF) and quality of life (QoL) treatment effects are important in treatment decision-making for older adults with cancer. However, data are limited for older men with metastatic castration-resistant prostate cancer (mCRPC). We evaluated the effects of treatment on PF and QoL in older men with mCRPC. MATERIALS AND METHODS Men aged 65+ with mCRPC were enrolled in this multicenter prospective observational study. PF measures included instrumental activities of daily living, grip strength, chair stands, and gait speed. QoL measures included fatigue, pain, mood, and Functional Assessment of Cancer Therapy (FACT)-General total and sub-scale scores. Outcomes were collected at baseline, three, and six months. Linear mixed effects regression models were used to examine PF and QoL differences over time across various treatment cohorts. RESULTS We enrolled 198 men starting chemotherapy (n = 71), abiraterone (n = 37), enzalutamide (n = 67), or radium-223 (n = 23). At baseline, men starting chemotherapy had worse measures of PF, QoL, pain, and mood than the other groups. Over time, all PF measures remained stable, pain improved, but functional wellbeing (FWB) and mood worsened significantly for all cohorts. However, change over time in all outcomes was not appreciably different between treatment cohorts. Worst-case sensitivity analyses identified attrition (ranging from 22 to 42% by six months) as a major limitation of our study, particularly for the radium-223 cohort. DISCUSSION FWB and mood were most prone to deterioration over time, whereas pain improved with treatment. Although patients initiating chemotherapy had worse baseline PF and QoL, chemotherapy was not associated with significantly greater worsening over time compared to other common therapies for mCRPC. These findings may assist in treatment discussions with patients. However, given the modest sample size, attrition, and timeframe of follow-up, the impact of treatment on PF and QoL outcomes in this setting requires further study, particularly for radium-223.
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Wong J, Doherty HR, Singh M, Choi S, Siddiqui N, Lam D, Liyanage N, Tomlinson G, Chung F. The prevention of delirium in elderly surgical patients with obstructive sleep apnea (PODESA): a randomized controlled trial. BMC Anesthesiol 2022; 22:290. [PMID: 36104664 PMCID: PMC9472354 DOI: 10.1186/s12871-022-01831-1] [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: 06/22/2022] [Accepted: 08/26/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with neurocognitive impairment - a known risk factor for postoperative delirium. However, it is unclear whether OSA increases the risk of postoperative delirium and whether treatment is protective. The objectives of this study were to identify OSA with a home sleep apnea test (HSAT) and to determine whether auto-titrating positive airway pressure (APAP) reduces postoperative delirium in older adults with newly diagnosed OSA undergoing elective hip or knee arthroplasty. METHODS We conducted a multi-centre, randomized controlled trial at three academic hospitals in Canada. Research ethics board approval was obtained from the participating sites and informed consent was obtained from participants. Inclusion criteria were patients who were [Formula: see text]0 years and scheduled for elective hip or knee replacement. Patients with a STOP-Bang score of ≥ 3 had a HSAT. Patients were defined as having OSA if the apnea-hypopnea index was ≥ 10/h. These patients were randomized 1:1 to either: 1) APAP for 72 h postoperatively or until discharge, or 2) routine care after surgery. The primary outcome was postoperative delirium, assessed twice daily with the Confusion Assessment Method for 72 h or until discharge or by chart review. The secondary outcome measures included length of stay, and perioperative complications occurring within 30 days after surgery. RESULTS Of 549 recruited patients, 474 completed a HSAT. A total of 234 patients with newly diagnosed OSA were randomized. The mean age was 68.2 (6.2) years and 58.6% were male. Analysis was performed on 220 patients. In total, 2.7% (6/220) patients developed delirium after surgery: 4.4% (5/114) patients in the routine care group, and 0.9% (1/106) patients in the treatment group (P = 0.21). The mean length of stay for the APAP vs. the routine care group was 2.9 (2.9) days vs. 3.5 (4.5) days (P = 0.24). On postoperative night 1, 53.5% of patients used APAP for 4 h/night or more, this decreased to 43.5% on night 2, and 24.6% on night 3. There was no difference in intraoperative and postoperative complications between the two groups. CONCLUSIONS We had an unexpectedly low rate of postoperative delirium thus we were unable to determine if postoperative delirium was reduced in older adults with newly diagnosed OSA receiving APAP vs. those who did not receive APAP after elective knee or hip arthroplasty. TRIAL REGISTRATION This trial was retrospectively registered in clinicaltrials.gov NCT02954224 on 03/11/2016.
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Affiliation(s)
- Jean Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON Canada ,grid.417199.30000 0004 0474 0188Department of Anesthesiology and Pain Medicine, Women’s College Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | - Helen R. Doherty
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON Canada
| | - Mandeep Singh
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON Canada ,grid.417199.30000 0004 0474 0188Department of Anesthesiology and Pain Medicine, Women’s College Hospital, Toronto, ON Canada
| | - Stephen Choi
- grid.17063.330000 0001 2157 2938Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON Canada
| | - Naveed Siddiqui
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Mount Sinai Hospital, University of Toronto, Toronto, ON Canada
| | - David Lam
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON Canada
| | - Nishanthi Liyanage
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON Canada
| | - George Tomlinson
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, Department of Medicine, University of Toronto, Toronto, ON M5G 2C4 Canada
| | - Frances Chung
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON Canada
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