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Markoulidakis A, Hickman M, McAuley A, Barnsdale LR, Welton NJ, Glancy M, Shivaji T, Collins C, Lang J, de Wit F, Hunt G, Wilkinson L, Fraser R, Yeung A, Horsburgh K, Priyadarshi S, Hutchinson SJ, Jones HE. Prevalence of opioid dependence in Scotland 2015-2020: A multi-parameter estimation of prevalence (MPEP) study. Addiction 2024. [PMID: 38631671 DOI: 10.1111/add.16500] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Drug-related deaths in Scotland more than doubled between 2011 and 2020. To inform policymakers and understand drivers of this increase, we estimated the number of people with opioid dependence aged 15-64 from 2014/15 to 2019/20. DESIGN We fitted a Bayesian multi-parameter estimation of prevalence (MPEP) model, using adverse event rates to estimate prevalence of opioid dependence jointly from Opioid Agonist Therapy (OAT), opioid-related mortality and hospital admissions data. Estimates are stratified by age group, sex and year. SETTING Scotland, 2014/15 to 2019/20. PARTICIPANTS People with opioid dependence and potential to benefit from OAT, whether ever treated or not. Using data from the Scottish Public Health Drug Linkage Programme, we identified a baseline cohort of individuals who had received OAT within the last 5 years, and all opioid-related deaths and hospital admissions (whether among or outside of this cohort). MEASUREMENTS Rates of each adverse event type and (unobserved) prevalence were jointly modelled. FINDINGS The estimated number and prevalence of people with opioid dependence in Scotland in 2019/20 was 47 100 (95% Credible Interval [CrI] 45 700 to 48 600) and 1.32% (95% CrI 1.28% to 1.37%). Of these, 61% received OAT during 2019/20. Prevalence in Greater Glasgow and Clyde was estimated as 1.77% (95% CrI 1.69% to 1.85%). There was weak evidence that overall prevalence fell slightly from 2014/15 (change -0.07%, 95% CrI -0.14% to 0.00%). The population of people with opioid dependence is ageing, with the estimated number of people aged 15-34 reducing by 5100 (95% CrI 3800 to 6400) and number aged 50-64 increasing by 2800 (95% CrI 2100 to 3500) between 2014/15 and 2019/20. CONCLUSIONS The prevalence of opioid dependence in Scotland remained high but was relatively stable, with only weak evidence of a small reduction, between 2014/15 and 2019/20. Increased numbers of opioid-related deaths can be attributed to increased risk among people with opioid dependence, rather than increasing prevalence.
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Affiliation(s)
- Andreas Markoulidakis
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Public Health Scotland, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew McAuley
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Megan Glancy
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | | | | | | | | | | | - Rosalyn Fraser
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Alan Yeung
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Saket Priyadarshi
- Alcohol and Drug Recovery Services, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Sharon J Hutchinson
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Kanagasabai A, Evans C, Jones HE, Hay AD, Dawson S, Savović J, Elwenspoek MMC. Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis. Clin Microbiol Infect 2024; 30:445-452. [PMID: 38182052 DOI: 10.1016/j.cmi.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 12/11/2023] [Accepted: 12/24/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Centor and McIsaac scores are clinical prediction rules for diagnosing group A streptococcus (GAS) infection in patients with pharyngitis. Their recommended thresholds vary between guidelines. OBJECTIVES To estimate the sensitivity and specificity of the McIsaac and Centor scores to diagnose GAS pharyngitis and evaluate their impact on antibiotic prescribing at each threshold in patients presenting to secondary care. DATA SOURCES MEDLINE, Embase, and Web of Science were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA Studies of patients presenting with acute pharyngitis to emergency or outpatient clinics that estimated the accuracy of McIsaac or Centor scores against throat cultures and/or rapid antigen detection tests (RADT) as reference standards. TESTS Centor or McIsaac score. REFERENCE STANDARD Throat cultures and/or RADT. ASSESSMENT OF RISK OF BIAS Quality Assessment of Diagnostic Accuracy Studies. METHODS OF DATA SYNTHESIS The sensitivities and specificities of the McIsaac and Centor scores were pooled at each threshold using bivariate random effects meta-analysis. RESULTS Fourteen studies were included (eight McIsaac and six Centor scores). Eight studies had unclear and six had a high risk of bias. The McIsaac score had higher estimated sensitivity and lower specificity relative to Centor scores at equivalent thresholds but with wide and overlapping confidence regions. Using either score as a triage to RADT to decide antibiotic treatment would reduce antibiotic prescription to patients with non-GAS pharyngitis relative to RADT test for everyone, but also reduce antibiotic prescription to patients with GAS. DISCUSSION Centor and McIsaac scores are equally ineffective at triaging patients who need antibiotics presenting with pharyngitis at hospitals. At high thresholds, too many true positive cases are missed, whereas at low thresholds, too many false positives are treated, leading to the over prescription of antibiotics. The former may be compensated by adequate safety netting by clinicians, ensuring that patients can seek help if symptoms worsen.
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Affiliation(s)
| | - Callum Evans
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Kehoe K, Morden E, Zinyakatira N, Heekes A, Jones HE, Walter SR, Jacobs T, Murray J, Buys H, Redaniel MT, Davies MA. Lower respiratory tract infection admissions and deaths among children under 5 years in public sector facilities in the Western Cape Province, South Africa, before and during the COVID-19 pandemic (2019 - 2021). S Afr Med J 2024; 114:e1560. [PMID: 38525574 DOI: 10.7196/samj.2024.v114i3.1560] [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: 09/22/2023] [Accepted: 11/27/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic resulted in the implementation of strict public health and social measures (PHSMs) (including mobility restrictions, social distancing, mask-wearing and hand hygiene), limitations on non-essential healthcare services, and public fear of COVID-19 infection, all of which potentially affected transmission and healthcare use for other diseases such as lower respiratory tract infections (LRTIs). OBJECTIVE To determine changes in LRTI hospital admissions and in-facility mortality in children aged <5 years in the Western Cape Province during the pandemic. METHODS We conducted a retrospective analysis of LRTI admissions and in-facility deaths from January 2019 to November 2021. We estimated changes in rates and trends of LRTI admissions during the pandemic compared with pre-pandemic period using interrupted time series analysis, adjusting for key characteristics. RESULTS There were 36 277 children admitted for LRTIs during the study period, of whom 58% were male and 51% were aged 28 days - 1 year. COVID-19 restrictions were associated with a 13% step reduction in LRTI admissions compared with the pre-COVID-19 period (incidence rate ratio (IRR) 0.87, 95% confidence interval (CI)) 0.80 - 0.94). The average LRTI admission trend increased on average by 2% per month during the pandemic (IRR 1.02, 95% CI 1.02 - 1.04). CONCLUSIONS The COVID-19 surges and their associated measures were linked to declining LRTI admissions and in-facility deaths, likely driven by a combination of reduced infectious disease transmission and reduced use of healthcare services, with effects diminishing over time. These findings may inform future pandemic response policies.
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Affiliation(s)
- K Kehoe
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, South Africa; Population Health Sciences, Bristol Medical School, University of Bristol, UK; Health Intelligence Directorate, Western Cape Government Health and Wellness, South Africa.
| | - E Morden
- Health Intelligence Directorate, Western Cape Government Health and Wellness, South Africa; Division of Public Health Medicine, School of Public Health, University of Cape Town, South Africa.
| | - N Zinyakatira
- Health Intelligence Directorate, Western Cape Government Health and Wellness, South Africa; Division of Public Health Medicine, School of Public Health, University of Cape Town, South Africa.
| | - A Heekes
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, South Africa; Health Intelligence Directorate, Western Cape Government Health and Wellness, South Africa.
| | - H E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, UK.
| | - S R Walter
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | - T Jacobs
- Health Intelligence Directorate, Western Cape Government Health and Wellness, South Africa.
| | - J Murray
- Department of Paediatrics & Neonatology, Paarl Hospital, Western Cape Government Health and Wellness, Paarl, South Africa.
| | - H Buys
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; Red Cross War Memorial Children's Hospital, Western Cape Government Health and Wellness, Cape Town, South Africa.
| | - M T Redaniel
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | - M-A Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, South Africa; Health Intelligence Directorate, Western Cape Government Health and Wellness, South Africa.
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Keeney E, Elwenspoek MMC, Jackson J, Roadevin C, Jones HE, O'Donnell R, Sheppard AL, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Mallett S, Whiting PF, Thom H. Identifying the Optimum Strategy for Identifying Adults and Children With Celiac Disease: A Cost-Effectiveness and Value of Information Analysis. Value Health 2024; 27:301-312. [PMID: 38154593 DOI: 10.1016/j.jval.2023.12.010] [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] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 11/08/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Celiac disease (CD) is thought to affect around 1% of people in the United Kingdom, but only approximately 30% are diagnosed. The aim of this work was to assess the cost-effectiveness of strategies for identifying adults and children with CD in terms of who to test and which tests to use. METHODS A decision tree and Markov model were used to describe testing strategies and model long-term consequences of CD. The analysis compared a selection of pre-test probabilities of CD above which patients should be screened, as well as the use of different serological tests, with or without genetic testing. Value of information analysis was used to prioritize parameters for future research. RESULTS Using serological testing alone in adults, immunoglobulin A (IgA) tissue transglutaminase (tTG) at a 1% pre-test probability (equivalent to population screening) was most cost-effective. If combining serological testing with genetic testing, human leukocyte antigen combined with IgA tTG at a 5% pre-test probability was most cost-effective. In children, the most cost-effective strategy was a 10% pre-test probability with human leukocyte antigen plus IgA tTG. Value of information analysis highlighted the probability of late diagnosis of CD and the accuracy of serological tests as important parameters. The analysis also suggested prioritizing research in adult women over adult men or children. CONCLUSIONS For adults, these cost-effectiveness results suggest UK National Screening Committee Criteria for population-based screening for CD should be explored. Substantial uncertainty in the results indicate a high value in conducting further research.
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Affiliation(s)
- Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Rachel O'Donnell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Athena L Sheppard
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK; Swansea University Medical School, Swansea University, Swansea, England, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh EH9 1LF Scotland, England, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, England, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, England, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Tomlinson E, Jones HE, James R, Cooper C, Stokes C, Begum S, Watson J, Hay AD, Ward M, Thom H, Whiting P. Clinical effectiveness of point of care tests for diagnosing urinary tract infection: a systematic review. Clin Microbiol Infect 2024; 30:197-205. [PMID: 37839580 DOI: 10.1016/j.cmi.2023.10.005] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/23/2023] [Accepted: 10/06/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Point of care tests (POCTs) have the potential to improve the urinary tract infection (UTI) diagnostic pathway, as they can provide a diagnosis quickly in near-patient settings, and some also identify causative pathogens/antimicrobial sensitivity. OBJECTIVES To assess the clinical impact, accuracy, and technical characteristics of POCT for diagnosing UTI. METHODS OF DATA SYNTHESIS Narrative summary and bivariate random effects meta-analyses to estimate summary sensitivity and specificity. DATA SOURCES Five electronic databases, two clinical trial registries, study reports and review reference lists, and websites. STUDY ELIGIBILITY CRITERIA Randomized controlled trials/non-randomized studies and diagnostic test accuracy studies published since 2000. PARTICIPANTS People with suspected UTI. TESTS Rapid tests (results <40 minutes): Astrego PA-100 system, Lodestar DX, Uriscreen, UTRiPLEX. Culture tests (results <24 hours): Flexicult Human, ID Flexicult, Diaslide, Dipstreak, Chromostreak, Uricult, Uricult Trio, Uricult Plus. REFERENCE STANDARD Any. ASSESSMENT OF RISK OF BIAS Risk of Bias-2, Quality Assessment of Diagnostic Accuracy Studies-2, Quality Assessment of Diagnostic Accuracy Studies-C. RESULTS Two randomized controlled trials evaluated Flexicult Human (one against standard care; one against ID Flexicult). No difference was reported in antibiotic use concordant with culture results (OR 0.84 95% CI 0.58-1.20) or appropriate antibiotic prescribing (OR 1.44 95% CI 1.03-1.99). Initial antibiotic prescribing was lower with Flexicult than standard care (OR 0.56 95% CI 0.35-0.88). No difference for other measures of antibiotic use, symptom duration, patient enablement, or resource use. Fifteen studies reported accuracy data. Limited data were available, with most POCT evaluated in single studies or not evaluated at all. Uriscreen (four studies), Uricult Trio (three studies), Flexicult Human (four studies), and ID Flexicult (two studies) had modest sensitivity and specificity. POCTs were easier to use and interpret than standard culture. CONCLUSIONS There is currently insufficient evidence to support the use of POCTs in UTI diagnosis. Due to the rapid development of POCT, this review should be updated regularly.
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Affiliation(s)
- Eve Tomlinson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel James
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Cooper
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Jessica Watson
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mary Ward
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Downing BC, Hickman M, Jones NR, Larney S, Sweeting MJ, Xu Y, Farrell M, Degenhardt L, Jones HE. Prevalence of opioid dependence in New South Wales, Australia, 2014-16: Indirect estimation from multiple data sources using a Bayesian approach. Addiction 2023; 118:1994-2006. [PMID: 37292044 DOI: 10.1111/add.16268] [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: 06/20/2022] [Accepted: 05/09/2023] [Indexed: 06/10/2023]
Abstract
AIMS To estimate the prevalence of, and number of unobserved people with opioid dependence by sex and age group in New South Wales (NSW), Australia. DESIGN We applied a Bayesian statistical modelling approach to opioid agonist treatment records linked to adverse event rate data. We estimated prevalence from three types of adverse event separately: opioid mortality, opioid-poisoning hospitalizations and opioid-related charges. We extended the model and produced prevalence estimates from a 'multi-source' model based on all three types of adverse event data. SETTING, PARTICIPANTS AND MEASUREMENTS This study was conducted in NSW, Australia, 2014-16 using data from the Opioid Agonist Treatment and Safety (OATS) study, which included all people who had received treatment for opioid dependence in NSW. Aggregate data were obtained on numbers of adverse events in NSW. Rates of each adverse event type within the OATS cohort were modelled. Population data were provided by State and Commonwealth agencies. FINDINGS Prevalence of opioid dependence among those aged 15-64 years in 2016 was estimated to be 0.96% (95% credible interval [CrI] = 0.82%, 1.12%) from the mortality model, 0.75% (95% CrI = 0.70%, 0.83%) from hospitalizations, 0.95% (95% CrI = 0.90%, 0.99%) from charges and 0.92% (95% CrI = 0.88%, 0.96%) from the multi-source model. Of the estimated 46 460 (95% CrI = 44 680, 48 410) people with opioid dependence in 2016 from the multi-source model, approximately one-third (16 750, 95% CrI = 14 960, 18 690) had no record of opioid agonist treatment within the last 4 years. From the multi-source model, prevalence in 2016 was estimated to be 1.24% (95% CrI = 1.18%, 1.31%) in men aged 15-44, 1.22% (95% CrI = 1.14%, 1.31%) in men 45-64, 0.63% (95% CrI = 0.59%, 0.68%) in women aged 15-44 and 0.56% (95% CrI = 0.50%, 0.63%) in women aged 45-64. CONCLUSIONS A Bayesian statistical approach to estimate prevalence from multiple adverse event types simultaneously calculates that the estimated prevalence of opioid dependence in NSW, Australia in 2016 was 0.92%, higher than previous estimates.
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Affiliation(s)
- Beatrice C Downing
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Montreal, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Yixin Xu
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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de Beer ST, Slogrove AL, Eley B, Ingle SM, Jones HE, Phelanyane F, Anderson K, Kalk E, Boulle A, Davies M. Change in HIV-related characteristics of children hospitalised with infectious diseases in Western Cape, South Africa, 2008-2021: a time trend analysis. J Int AIDS Soc 2023; 26 Suppl 4:e26151. [PMID: 37909168 PMCID: PMC10618898 DOI: 10.1002/jia2.26151] [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: 01/27/2023] [Accepted: 08/15/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION With the scaling up of vertical HIV transmission prevention programmes, the HIV-related population profile of children in South Africa has shifted. We described temporal changes in HIV-related characteristics of children, aged ≤3 years (up to the third birthday), with infectious disease hospitalisations across the Western Cape province. METHODS We used routinely collected electronic data to identify children born in the Western Cape with infectious disease hospital records for lower respiratory tract infections, diarrhoea, meningitis and tuberculous meningitis, from 2008 to 2021. Linked maternal and child unique identifiers were used to extract pregnancy, HIV-related, laboratory, pharmacy and hospitalisation data. We described temporal changes in child HIV exposure and acquisition status, timing of maternal HIV diagnosis and antiretroviral therapy (ART) start, infant exposure to maternal ART and timing thereof, and maternal CD4 and HIV viral load closest to delivery. We used logistic and multinomial regression to assess changes in characteristics between the Pre-Option B+ (2008-2013), Option B+ (2013-2016) and Universal ART periods (2016-2021). RESULTS Among 52,811 children aged ≤3 years with hospitalisations, the proportion living with HIV dreased from 7.0% (2008) to 1.1% (2021), while those exposed to HIV and uninfected increased from 14.0% (2008) to 16.1% (2021) with a peak of 18.3% in 2017. Among mothers with HIV (n = 9873), the proportion diagnosed with HIV and starting ART before pregnancy increased from 20.2% to 69.2% and 5.8% to 59.0%, respectively, between 2008 and 2021. Children hospitalised during the Universal ART period had eight times higher odds (Odds Ratio: 8.41; 95% CI: 7.36-9.61) of exposure to maternal ART versus children admitted Pre-Option B+. Among mothers of children exposed to HIV and uninfected with CD4 records (n = 7523), the proportion with CD4 <350 cells/μl decreased from 90.6% (2008) to 27.8% (2021). CONCLUSIONS In recent years, among children hospitalised with infectious diseases, there were fewer children with perinatally acquired HIV, while an increased proportion of those without HIV acquisition are exposed to maternal HIV and ART. There is a need to look beyond paediatric HIV prevalence and consider child exposure to HIV and ART among children without HIV, when assessing the HIV epidemic's impact on child health services.
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Affiliation(s)
- Shani T. de Beer
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Health Intelligence DirectorateWestern Cape Government HealthCape TownSouth Africa
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Amy L. Slogrove
- Department of Paediatrics & Child HealthFaculty of Medicine & Health Sciences, Stellenbosch UniversityWorcesterSouth Africa
| | - Brian Eley
- Paediatric Infectious Diseases UnitRed Cross War Memorial Children's Hospital and the Department of Paediatrics and Child HealthUniversity of Cape TownCape TownSouth Africa
| | - Suzanne M. Ingle
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hayley E. Jones
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Florence Phelanyane
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Health Intelligence DirectorateWestern Cape Government HealthCape TownSouth Africa
| | - Kim Anderson
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Health Intelligence DirectorateWestern Cape Government HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Health Intelligence DirectorateWestern Cape Government HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
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8
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Kilpi F, Jones HE, Magnus MC, Santorelli G, Højsgaard Schmidt LK, Urhoj SK, Nelson SM, Tuffnell D, French R, Magnus PM, Nybo Andersen AM, Martikainen P, Tilling K, Lawlor DA. Association between perinatal mortality and morbidity and customised and non-customised birthweight centiles in Denmark, Finland, Norway, Wales, and England: comparative, population based, record linkage study. BMJ Med 2023; 2:e000521. [PMID: 37663045 PMCID: PMC10471867 DOI: 10.1136/bmjmed-2023-000521] [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] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023]
Abstract
Objectives To compare the risk of adverse perinatal outcomes according to infants who are born small for gestational age (SGA; <10th centile) or large for gestational age (LGA; >90th centile), as defined by birthweight centiles that are non-customised (ie, standardised by sex and gestational age only) and customised (by sex, gestational age, maternal weight, height, parity, and ethnic group). Design Comparative, population based, record linkage study with meta-analysis of results. Setting Denmark, Finland, Norway, Wales, and England (city of Bradford), 1986-2019. Participants 2 129 782 infants born at term in birth registries. Main outcome measures Stillbirth, neonatal death, infant death, admission to neonatal intensive care unit, and low Apgar score (<7) at 5 minutes. Results Relative to those infants born average for gestational age (AGA), both SGA and LGA births were at increased risk of all five outcomes, but observed relative risks were similar irrespective of whether non-customised or customised charts were used. For example, for SGA versus AGA births, when non-customised and customised charts were used, relative risks pooled over countries were 3.60 (95% confidence interval 3.29 to 3.93) versus 3.58 (3.02 to 4.24) for stillbirth, 2.83 (2.18 to 3.67) versus 3.32 (2.05 to 5.36) for neonatal death, 2.82 (2.07 to 3.83) versus 3.17 (2.20 to 4.56) for infant death, 1.66 (1.49 to 1.86) versus 1.54 (1.30 to 1.81) for low Apgar score at 5 minutes, and (based on Bradford data only) 1.97 (1.74 to 2.22) versus 1.94 (1.70 to 2.21) for admission to the neonatal intensive care unit. The estimated sensitivity of combined SGA or LGA births to identify the three mortality outcomes ranged from 31% to 34% for non-customised charts and from 34% to 38% for customised charts, with a specificity of 82% and 80% with non-customised and customised charts, respectively. Conclusions These results suggest an increased risk of adverse perinatal outcomes of a similar magnitude among SGA or LGA term infants when customised and non-customised centiles are used. Use of customised charts for SGA/LGA births-over and above use of non-customised charts for SGA/LGA births-is unlikely to provide benefits in terms of identifying term births at risk of these outcomes.
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Affiliation(s)
- Fanny Kilpi
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Christine Magnus
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | | | | | - Stine Kjaer Urhoj
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Scott M Nelson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | | | | | - Per Minor Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Pekka Martikainen
- Population Research Unit, University of Helsinki Faculty of Social Sciences, Helsinki, Uusimaa, Finland
- Max Planck Institute for Demographic Research, Rostock, Germany
| | - Kate Tilling
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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9
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McAuley A, Fraser R, Glancy M, Yeung A, Jones HE, Vickerman P, Fraser H, Allen L, McDonald SA, Stone J, Liddell D, Barnsdale L, Priyadarshi S, Markoulidakis A, Hickman M, Hutchinson SJ. Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011-20: a national retrospective cohort study. Lancet Public Health 2023; 8:e484-e493. [PMID: 37295452 DOI: 10.1016/s2468-2667(23)00082-8] [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: 12/16/2022] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Drug-related death (DRD) rate in Scotland, UK, has increased rapidly to one of the highest in the world. Our aim was to examine the extent to which opioid-agonist therapy (OAT) in Scotland is protective against drug-related mortality and how this effect has varied over time. METHODS We included individuals in Scotland with opioid use disorder who received at least one OAT prescription between Jan 1, 2011, and Dec 31, 2020. We calculated drug-related mortality rates and used Quasi-Poisson regression models to estimate trends over time and by OAT exposure, adjusting for potential confounding. FINDINGS In a cohort of 46 453 individuals prescribed OAT with a total of 304 000 person-years of follow-up, DRD rates more than trebled from 6·36 per 1000 person-years (95% CI 5·73-7·01) in 2011-12 to 21·45 (20·31-22·63) in 2019-20. DRD rates were almost three and a half times higher (hazard ratio 3·37; 95% CI 1·74-6·53) for those off OAT compared with those on OAT after adjustment for confounders. However, confounder adjusted DRD risk increased over time for both people off and on OAT. INTERPRETATION Drug-related mortality rates among people with opioid use disorders in Scotland increased between 2011 and 2020. OAT remains protective but is insufficient on its own to slow the increase in DRD risk for people who are opioid dependent in Scotland. FUNDING Scottish Government Drug Deaths Taskforce, Public Health Scotland, and National Institute for Health and Care Research.
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Affiliation(s)
- Andrew McAuley
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Edinburgh, UK.
| | - Rosalyn Fraser
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Edinburgh, UK
| | - Megan Glancy
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Edinburgh, UK
| | - Alan Yeung
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Edinburgh, UK
| | - Hayley E Jones
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Hannah Fraser
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Lara Allen
- Public Health Scotland, Edinburgh, UK; Bristol Medical School, University of Bristol, Bristol, UK
| | - Scott A McDonald
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Edinburgh, UK
| | - Jack Stone
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Saket Priyadarshi
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Glasgow Alcohol and Drug Recovery Services, Glasgow, UK
| | - Andreas Markoulidakis
- Public Health Scotland, Edinburgh, UK; Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sharon J Hutchinson
- School of Health and Life Sciences, Research Centre for Health, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Edinburgh, UK
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10
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Cerullo E, Sutton AJ, Jones HE, Wu O, Quinn TJ, Cooper NJ. MetaBayesDTA: codeless Bayesian meta-analysis of test accuracy, with or without a gold standard. BMC Med Res Methodol 2023; 23:127. [PMID: 37231347 PMCID: PMC10210277 DOI: 10.1186/s12874-023-01910-y] [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: 11/27/2022] [Accepted: 03/31/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The statistical models developed for meta-analysis of diagnostic test accuracy studies require specialised knowledge to implement. This is especially true since recent guidelines, such as those in Version 2 of the Cochrane Handbook of Systematic Reviews of Diagnostic Test Accuracy, advocate more sophisticated methods than previously. This paper describes a web-based application - MetaBayesDTA - that makes many advanced analysis methods in this area more accessible. RESULTS We created the app using R, the Shiny package and Stan. It allows for a broad array of analyses based on the bivariate model including extensions for subgroup analysis, meta-regression and comparative test accuracy evaluation. It also conducts analyses not assuming a perfect reference standard, including allowing for the use of different reference tests. CONCLUSIONS Due to its user-friendliness and broad array of features, MetaBayesDTA should appeal to researchers with varying levels of expertise. We anticipate that the application will encourage higher levels of uptake of more advanced methods, which ultimately should improve the quality of test accuracy reviews.
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Affiliation(s)
- Enzo Cerullo
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK.
- Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK.
| | - Alex J Sutton
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
- Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK
| | - Hayley E Jones
- Population Health Sciences, University of Bristol, Bristol Medical School, Bristol, UK
| | - Olivia Wu
- Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK
| | - Terry J Quinn
- Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nicola J Cooper
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
- Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK
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11
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Padmanathan P, Hall K, Moran P, Jones HE, Gunnell D, Carlisle V, Lingford-Hughes A, Hickman M. Corrigendum to "Prevention of suicide and reduction of self-harm among people with substance use disorder: A systematic review and meta-analysis of randomised controlled trials" [Comprehensive Psychiatry, volume 96 (2020)]. Compr Psychiatry 2022; 119:152296. [PMID: 35120731 DOI: 10.1016/j.comppsych.2022.152296] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Prianka Padmanathan
- Population Health Sciences, Bristol Medical School, University of Bristol, UK.
| | - Katherine Hall
- Avon & Wiltshire Mental Health Partnership NHS Trust, UK
| | - Paul Moran
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health Research, Biomedical Research Centre, University Hospitals Bristol, NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - David Gunnell
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health Research, Biomedical Research Centre, University Hospitals Bristol, NHS Foundation Trust, University of Bristol, Bristol, UK
| | | | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health Research, Biomedical Research Centre, University Hospitals Bristol, NHS Foundation Trust, University of Bristol, Bristol, UK
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12
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Findlater L, Trickey A, Jones HE, Trindall A, Taylor-Phillips S, Mulchandani R, Oliver I, Wyllie D. Association of Results of Four Lateral Flow Antibody Tests with Subsequent SARS-CoV-2 Infection. Microbiol Spectr 2022; 10:e0246822. [PMID: 36135374 PMCID: PMC9602656 DOI: 10.1128/spectrum.02468-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/06/2022] [Indexed: 01/04/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine coverage remains incomplete, being only 15% in low-income countries. Rapid point-of-care tests predicting SARS-CoV-2 infection susceptibility in the unvaccinated may assist in risk management and vaccine prioritization. We conducted a prospective cohort study in 2,826 participants working in hospitals and Fire and Police services in England, UK, during the pandemic (ISRCTN5660922). Plasma taken at recruitment in June 2020 was tested using four lateral flow immunoassay (LFIA) devices and two laboratory immunoassays detecting antibodies against SARS-CoV-2 (UK Rapid Test Consortium's AbC-19 rapid test, OrientGene COVID IgG/IgM rapid test cassette, SureScreen COVID-19 rapid test cassette, and Biomerica COVID-19 IgG/IgM rapid test; Roche N and Euroimmun S laboratory assays). We monitored participants for microbiologically confirmed SARS-CoV-2 infection for 200 days. We estimated associations between test results at baseline and subsequent infection, using Poisson regression models adjusted for baseline demographic risk factors for SARS-CoV-2 exposure. Positive IgG results on each of the four LFIAs were associated with lower rates of subsequent infection with adjusted incidence rate ratios (aIRRs) of 0.00 (95% confidence interval, 0.00 to 0.01), 0.03 (0.02 to 0.05), 0.07 (0.05 to 0.10), and 0.09 (0.07 to 0.12), respectively. The protective association was strongest for AbC-19 and SureScreen. The aIRR for the laboratory Roche N antibody assay at the manufacturer-recommended threshold was similar to those of the two best performing LFIAs at 0.03 (0.01 to 0.10). Lateral flow devices measuring SARS-CoV-2 IgG predicted disease risk in unvaccinated individuals over a 200-day follow-up. The association of some LFIAs with subsequent infection was similar to laboratory immunoassays. IMPORTANCE Previous research has demonstrated an association between the detection of antibodies to SARS-CoV-2 following natural infection and protection from subsequent symptomatic SARS-CoV-2 infection. Lateral flow immunoassays (LFIAs) detecting anti-SARS-CoV-2 IgG are a cheap, readily deployed technology that has been used on a large scale in population screening programs, yet no studies have investigated whether LFIA results are associated with subsequent SARS-CoV-2 infection. In a prospective cohort study of 2,826 United Kingdom key workers, we found positivity in lateral flow test results had a strong negative association with subsequent SARS-CoV-2 infection within 200 days in an unvaccinated population. Positivity on more-specific but less-sensitive tests was associated with a markedly decreased rate of disease; protection associated with testing positive using more sensitive devices detecting lower levels of anti-SARS-CoV-2 IgG was more modest. Lateral flow tests with high specificity may have a role in estimation of SARS-CoV-2 disease risk in unvaccinated populations.
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Affiliation(s)
- Lucy Findlater
- UK Health Security Agency, Cambridge, United Kingdom
- National Institute of Health Research Health Protection Research Unit on Behavioural Science and Evaluation at the University of Bristol, Bristol, United Kingdom
| | - Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Hayley E. Jones
- National Institute of Health Research Health Protection Research Unit on Behavioural Science and Evaluation at the University of Bristol, Bristol, United Kingdom
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Amy Trindall
- UK Health Security Agency, Cambridge, United Kingdom
| | | | | | - EDSAB-HOME Investigators
- UK Health Security Agency, Cambridge, United Kingdom
- National Institute of Health Research Health Protection Research Unit on Behavioural Science and Evaluation at the University of Bristol, Bristol, United Kingdom
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
- University of Warwick, Coventry, United Kingdom
| | - Isabel Oliver
- UK Health Security Agency, Cambridge, United Kingdom
- National Institute of Health Research Health Protection Research Unit on Behavioural Science and Evaluation at the University of Bristol, Bristol, United Kingdom
| | - David Wyllie
- UK Health Security Agency, Cambridge, United Kingdom
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13
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Elwenspoek MM, Thom H, Sheppard AL, Keeney E, O'Donnell R, Jackson J, Roadevin C, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Jones HE, Mallett S, Whiting PF. Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling. Health Technol Assess 2022; 26:1-310. [PMID: 36321689 PMCID: PMC9638887 DOI: 10.3310/zuce8371] [Citation(s) in RCA: 6] [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] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. OBJECTIVES The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. DESIGN (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. DATA SOURCES For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. REVIEW METHODS For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. RESULTS People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. LIMITATIONS The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. CONCLUSIONS Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia). FUTURE WORK Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42019115506 and CRD42020170766. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martha Mc Elwenspoek
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athena L Sheppard
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel O'Donnell
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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14
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Cerullo E, Jones HE, Carter O, Quinn TJ, Cooper NJ, Sutton AJ. Meta-analysis of dichotomous and ordinal tests with an imperfect gold standard. Res Synth Methods 2022; 13:595-611. [PMID: 35488506 PMCID: PMC9541315 DOI: 10.1002/jrsm.1567] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/14/2022] [Accepted: 03/29/2022] [Indexed: 11/07/2022]
Abstract
Standard methods for the meta-analysis of medical tests, without assuming a gold standard, are limited to dichotomous data. Multivariate probit models are used to analyse correlated dichotomous data, and can be extended to model ordinal data. Within the context of an imperfect gold standard, they have previously been used for the analysis of dichotomous and ordinal test data from a single study, and for the meta-analysis of dichotomous tests. However, they have not previously been used for the meta-analysis of ordinal tests. In this article, we developed a Bayesian multivariate probit latent class model for the simultaneous meta-analysis of ordinal and dichotomous tests without assuming a gold standard, which also allows one to obtain summary estimates of joint test accuracy. We fitted the models using the software Stan, which uses a state-of-the-art Hamiltonian Monte Carlo algorithm, and we applied the models to a dataset in which studies evaluated the accuracy of tests, and test combinations, for deep vein thrombosis. We demonstrate the issues with dichotomising ordinal test accuracy data in the presence of an imperfect gold standard, before applying and comparing several variations of our proposed model which do not require the data to be dichotomised. The models proposed will allow researchers to more appropriately meta-analyse ordinal and dichotomous tests without a gold standard, potentially leading to less biased estimates of test accuracy. This may lead to a better understanding of which tests, and test combinations, should be used for any given medical condition.
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Affiliation(s)
- Enzo Cerullo
- Biostatistics Research Group, Department of Health SciencesUniversity of LeicesterLeicesterLeicestershireUK
- Complex Reviews Support UnitUniversity of Leicester & University of GlasgowGlasgowUK
| | - Hayley E. Jones
- Population Health SciencesBristol Medical School, University of BristolBristolUK
| | | | - Terry J. Quinn
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowScotlandUK
| | - Nicola J. Cooper
- Biostatistics Research Group, Department of Health SciencesUniversity of LeicesterLeicesterLeicestershireUK
- Complex Reviews Support UnitUniversity of Leicester & University of GlasgowGlasgowUK
| | - Alex J. Sutton
- Biostatistics Research Group, Department of Health SciencesUniversity of LeicesterLeicesterLeicestershireUK
- Complex Reviews Support UnitUniversity of Leicester & University of GlasgowGlasgowUK
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15
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Weller SA, Armstrong SR, Bailey S, Burnell HT, Burt EL, Cant NE, Cawthorne KR, Chester M, Choules JE, Coe NA, Coward L, Cox VL, Emery ER, Evans CP, Finn A, Halford CM, Hamblin KA, Harrison GV, Hartley MG, Hudson C, James B, Jones HE, Keyser E, Lonsdale CL, Marshall LE, Maule CE, Miles JA, Newstead SL, Nicholls M, Osborne C, Pearcy AS, Penny LD, Perrot R, Rachwal P, Robinson V, Rushton D, Stahl FM, Staplehurst SV, Stapleton HL, Steeds K, Stephenson K, Thompson IJ, Thwaite JE, Ulaeto DO, Waters N, Wills DJ, Wills ZS, Rees C, Hutley EJ. Development and operation of the defence COVID-19 lab as a SARS-CoV-2 diagnostic screening capability for UK military personnel. BMJ Mil Health 2022; 170:e002134. [PMID: 35878971 PMCID: PMC10958320 DOI: 10.1136/military-2022-002134] [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: 05/04/2022] [Accepted: 07/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND In the face of the COVID-19 pandemic, the Defence Science and Technology Laboratory (Dstl) and Defence Pathology combined to form the Defence Clinical Lab (DCL), an accredited (ISO/IEC 17025:2017) high-throughput SARS-CoV-2 PCR screening capability for military personnel. LABORATORY STRUCTURE AND RESOURCE The DCL was modular in organisation, with laboratory modules and supporting functions combining to provide the accredited SARS-CoV-2 (envelope (E)-gene) PCR assay. The DCL was resourced by Dstl scientists and military clinicians and biomedical scientists. LABORATORY RESULTS Over 12 months of operation, the DCL was open on 289 days and tested over 72 000 samples. Six hundred military SARS-CoV-2-positive results were reported with a median E-gene quantitation cycle (Cq) value of 30.44. The lowest Cq value for a positive result observed was 11.20. Only 64 samples (0.09%) were voided due to assay inhibition after processing started. CONCLUSIONS Through a sustained effort and despite various operational issues, the collaboration between Dstl scientific expertise and Defence Pathology clinical expertise provided the UK military with an accredited high-throughput SARS-CoV-2 PCR test capability at the height of the COVID-19 pandemic. The DCL helped facilitate military training and operational deployments contributing to the maintenance of UK military capability. In offering a bespoke capability, including features such as testing samples in unit batches and oversight by military consultant microbiologists, the DCL provided additional benefits to the UK Ministry of Defence that were potentially not available from other SARS-CoV-2 PCR laboratories. The links between Dstl and Defence Pathology have also been strengthened, benefitting future research activities and operational responses.
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Affiliation(s)
- Simon A Weller
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S R Armstrong
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S Bailey
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - H T Burnell
- Operations Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - E L Burt
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - N E Cant
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K R Cawthorne
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - M Chester
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - J E Choules
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - N A Coe
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - L Coward
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - V L Cox
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - E R Emery
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C P Evans
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - A Finn
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C M Halford
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K A Hamblin
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - G V Harrison
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - M G Hartley
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C Hudson
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - B James
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - H E Jones
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - E Keyser
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C L Lonsdale
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - L E Marshall
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C E Maule
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - J A Miles
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S L Newstead
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - M Nicholls
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Osborne
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - A S Pearcy
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - L D Penny
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - R Perrot
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - P Rachwal
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - V Robinson
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - D Rushton
- Platform Systems Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - F M Stahl
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S V Staplehurst
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - H L Stapleton
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K Steeds
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K Stephenson
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - I J Thompson
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - J E Thwaite
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - D O Ulaeto
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - N Waters
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - D J Wills
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - Z S Wills
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C Rees
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - E J Hutley
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
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16
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Brandner S, McAleenan A, Jones HE, Kernohan A, Robinson T, Schmidt L, Dawson S, Kelly C, Leal ES, Faulkner CL, Palmer A, Wragg C, Jefferies S, Vale L, Higgins JPT, Kurian KM. Diagnostic accuracy of 1p/19q codeletion tests in oligodendroglioma: A comprehensive meta-analysis based on a Cochrane systematic review. Neuropathol Appl Neurobiol 2022; 48:e12790. [PMID: 34958131 PMCID: PMC9208578 DOI: 10.1111/nan.12790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/23/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022]
Abstract
Codeletion of chromosomal arms 1p and 19q, in conjunction with a mutation in the isocitrate dehydrogenase 1 or 2 gene, is the molecular diagnostic criterion for oligodendroglioma, IDH mutant and 1p/19q codeleted. 1p/19q codeletion is a diagnostic marker and allows prognostication and prediction of the best drug response within IDH-mutant tumours. We performed a Cochrane review and simple economic analysis to establish the most sensitive, specific and cost-effective techniques for determining 1p/19q codeletion status. Fluorescent in situ hybridisation (FISH) and polymerase chain reaction (PCR)-based loss of heterozygosity (LOH) test methods were considered as reference standard. Most techniques (FISH, chromogenic in situ hybridisation [CISH], PCR, real-time PCR, multiplex ligation-dependent probe amplification [MLPA], single nucleotide polymorphism [SNP] array, comparative genomic hybridisation [CGH], array CGH, next-generation sequencing [NGS], mass spectrometry and NanoString) showed good sensitivity (few false negatives) for detection of 1p/19q codeletions in glioma, irrespective of whether FISH or PCR-based LOH was used as the reference standard. Both NGS and SNP array had a high specificity (fewer false positives) for 1p/19q codeletion when considered against FISH as the reference standard. Our findings suggest that G banding is not a suitable test for 1p/19q analysis. Within these limits, considering cost per diagnosis and using FISH as a reference, MLPA was marginally more cost-effective than other tests, although these economic analyses were limited by the range of available parameters, time horizon and data from multiple healthcare organisations.
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Affiliation(s)
- Sebastian Brandner
- Division of Neuropathology, The National Hospital for Neurology and NeurosurgeryUniversity College London Hospitals NHS Foundation TrustLondonUK
- Department of Neurodegenerative Disease, Queen Square Instituite of NeurologyUniversity College LondonLondonUK
| | - Alexandra McAleenan
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Hayley E. Jones
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Ashleigh Kernohan
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Tomos Robinson
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Lena Schmidt
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Claire Kelly
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | | | - Claire L. Faulkner
- Bristol Genetics Laboratory, Pathology SciencesSouthmead HospitalBristolUK
| | - Abigail Palmer
- Bristol Genetics Laboratory, Pathology SciencesSouthmead HospitalBristolUK
| | - Christopher Wragg
- Bristol Genetics Laboratory, Pathology SciencesSouthmead HospitalBristolUK
| | | | - Luke Vale
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Julian P. T. Higgins
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kathreena M. Kurian
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
- Bristol Medical School: Brain Tumour Research Centre, Public Health SciencesUniversity of BristolBristolUK
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17
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Andrews LJ, Thornton ZA, Saincher SS, Yao IY, Dawson S, McGuinness LA, Jones HE, Jefferies S, Short SC, Cheng HY, McAleenan A, Higgins JPT, Kurian KM. Prevalence of BRAFV600 in glioma and use of BRAF Inhibitors in patients with BRAFV600 mutation-positive glioma: systematic review. Neuro Oncol 2022; 24:528-540. [PMID: 34718782 PMCID: PMC8972326 DOI: 10.1093/neuonc/noab247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Detailed prevalence estimates of BRAFV600 mutations and BRAF inhibitor (BRAFi) treatment responses in V600-mutant glioma will inform trial development. METHODS Our systematic review analyzed overall prevalence of BRAFV600 mutations in glioma and BRAFi treatment response. RESULTS Based on 13 682 patients in 182 publications, the prevalence of BRAFV600 in epithelioid glioblastoma (eGBM) was 69% [95% CI: 45-89%]; pleomorphic xanthoastrocytoma (PXA): 56% [48-64%] anaplastic pleomorphic xanthoastrocytoma (aPXA): 38% [23-54%], ganglioglioma (GG): 40% [33-46%], and anaplastic ganglioglioma (aGG): 46% [18-76%]. Prevalence in astroblastoma was 24% [8-43%], desmoplastic infantile astrocytoma (DIA): 16% [0-57%], subependymal giant cell astrocytoma (SEGA): 8% [0-37%], dysembryoplastic neuroepithelial tumor (DNET): 3% [0-11%], diffuse astrocytoma (DA): 3% [0-9%], and pilocytic astrocytoma (PA): 3% [2-5%]. We reviewed 394 V600-mutant gliomas treated with BRAFi from 130 publications. One hundred and twenty-nine pediatric low-grade gliomas showed 4 (3.1%) complete response (CR); 53 (41.1%) partial response (PR); 64 (49.6%) stable disease (SD) and 8 (6.2%) progressive disease (PD). 25 pediatric high-grade gliomas showed CR; PR; SD; PD in 4 (16.0%); 10 (40.0%), 4 (16.0%); and 7 (28.0%) respectively. Thirty-nine adult low-grade gliomas showed CR; PR; SD; PD of 4 (10.3%); 17 (43.6%); 16 (41.0%) and 2 (5.1%) respectively. Ninety-seven adult high-grade gliomas showed CR; PR; SD; PD of 6 (6.2%); 31 (32.0%); 27 (27.8%); and 33 (34.0%) respectively. CONCLUSIONS BRAFV600 prevalence is highest in eGBM, PXA, aPXA, GG, aGG, and lower in astroblastoma, DIA, SEGA, DNET, DA, and PA. Our data provide the rationale for adjuvant clinical trials of BRAFi in V600-mutant glioma.
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Affiliation(s)
- Lily J Andrews
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research Integrative Cancer Epidemiology Programme, University of Bristol, Bristol, UK
| | - Zak A Thornton
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research Integrative Cancer Epidemiology Programme, University of Bristol, Bristol, UK
| | - Saanwalshah S Saincher
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ian Y Yao
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Luke A McGuinness
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
| | - Susan C Short
- Brain Cancer Research Group, Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Hung-Yuan Cheng
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research Integrative Cancer Epidemiology Programme, University of Bristol, Bristol, UK
| | - Julian P T Higgins
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kathreena M Kurian
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research Integrative Cancer Epidemiology Programme, University of Bristol, Bristol, UK
- Brain Tumour Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
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18
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Elwenspoek MM, O'Donnell R, Jackson J, Everitt H, Gillett P, Hay AD, Jones HE, Robins G, Watson JC, Mallett S, Whiting P. Development and external validation of a clinical prediction model to aid coeliac disease diagnosis in primary care: An observational study. EClinicalMedicine 2022; 46:101376. [PMID: 35434586 PMCID: PMC9011008 DOI: 10.1016/j.eclinm.2022.101376] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Coeliac disease (CD) affects approximately 1% of the population, although only a fraction of patients are diagnosed. Our objective was to develop diagnostic prediction models to help decide who should be offered testing for CD in primary care. METHODS Logistic regression models were developed in Clinical Practice Research Datalink (CPRD) GOLD (between Sep 9, 1987 and Apr 4, 2021, n=107,075) and externally validated in CPRD Aurum (between Jan 1, 1995 and Jan 15, 2021, n=227,915), two UK primary care databases, using (and controlling for) 1:4 nested case-control designs. Candidate predictors included symptoms and chronic conditions identified in current guidelines and using a systematic review of the literature. We used elastic-net regression to further refine the models. FINDINGS The prediction model included 24, 24, and 21 predictors for children, women, and men, respectively. For children, the strongest predictors were type 1 diabetes, Turner syndrome, IgA deficiency, or first-degree relatives with CD. For women and men, these were anaemia and first-degree relatives. In the development dataset, the models showed good discrimination with a c-statistic of 0·84 (95% CI 0·83-0·84) in children, 0·77 (0·77-0·78) in women, and 0·81 (0·81-0·82) in men. External validation discrimination was lower, potentially because 'first-degree relative' was not recorded in the dataset used for validation. Model calibration was poor, tending to overestimate CD risk in all three groups in both datasets. INTERPRETATION These prediction models could help identify individuals with an increased risk of CD in relatively low prevalence populations such as primary care. Offering a serological test to these patients could increase case finding for CD. However, this involves offering tests to more people than is currently done. Further work is needed in prospective cohorts to refine and confirm the models and assess clinical and cost effectiveness. FUNDING National Institute for Health Research Health Technology Assessment Programme (grant number NIHR129020).
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Affiliation(s)
- Martha M.C. Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, BS1 2NT, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
- Corresponding author. Martha M.C. Elwenspoek, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT. Tel: +44/0 117 3427689.
| | - Rachel O'Donnell
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, BS1 2NT, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, BS1 2NT, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Hazel Everitt
- Primary Care Research Centre, University of Southampton, Southampton SO16 5ST, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh EH9 1LF, Scotland, UK
| | - Alastair D. Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Hayley E. Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, YO31 8HE, UK
| | - Jessica C. Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, 2nd Floor, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
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19
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Jones HE, Morrison I, Hurding S, Wild S, Anand A, Shenkin SD. 709 IMPACT ON HEALTHCARE UTILISATION OF A GENERAL PRACTITIONER-LED MODEL OF CARE FOR PATIENTS WITH FRAILTY. Age Ageing 2022. [DOI: 10.1093/ageing/afac035.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Primary care has a significant role to play in the identification and management of frailty. MidMed is a new dedicated GP-led service developed by a large practice in Midlothian for patients living at home with moderate or severe frailty. MidMed comprises a full-time GP performing a comprehensive geriatric assessment (CGA) adapted for primary care. Patients receive direct access to all appointments with the named GP. The aim of this study was to assess the impact of MidMed on healthcare utilisation in this patient group.
Methods
Patients with moderate or severe frailty at the MidMed practice were identified by the electronic Frailty Index (>0.24). After 16 months, patients who had been accepted into MidMed (MidMed group) were compared with those yet to be enrolled and who continued to receive usual care (non-MidMed group). Routinely collected data were used to identify outcomes including unscheduled hospital admissions, primary care consultations, continuity of care, outpatient attendances and mortality. Adjusted rate ratios were estimated using regression models.
Results
510 patients with moderate or severe frailty were identified (290 in MidMed, 220 in non-MidMed). Patients in each group were just as likely to have at least one hospital admission per year but those in MidMed had a reduced risk of further hospital admission compared to the non-MidMed group (adjusted RR 0.46 [95%CI 0.30–0.71]). MidMed was also associated with statistically significant higher usage of primary care (adjusted RR 1.52, [95%CI, 1.30–1.75]) and better continuity of care. There was no difference in mortality or the number of outpatient appointments when adjusted for co-variates.
Conclusion
A GP-led service for frailty is associated with lower risk of hospital readmission and improved continuity of care. Further studies are now required to better understand why use of such primary care services increase and whether this changes over time.
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Affiliation(s)
| | | | | | - S Wild
- The Usher Institute, University of Edinburgh
| | - A Anand
- The Centre for Cardiovascular Science, University of Edinburgh
| | - S D Shenkin
- The Usher Institute, University of Edinburgh
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20
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McAleenan A, Jones HE, Kernohan A, Robinson T, Schmidt L, Dawson S, Kelly C, Spencer Leal E, Faulkner CL, Palmer A, Wragg C, Jefferies S, Brandner S, Vale L, Higgins JP, Kurian KM. Diagnostic test accuracy and cost-effectiveness of tests for codeletion of chromosomal arms 1p and 19q in people with glioma. Cochrane Database Syst Rev 2022; 3:CD013387. [PMID: 35233774 PMCID: PMC8889390 DOI: 10.1002/14651858.cd013387.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Complete deletion of both the short arm of chromosome 1 (1p) and the long arm of chromosome 19 (19q), known as 1p/19q codeletion, is a mutation that can occur in gliomas. It occurs in a type of glioma known as oligodendroglioma and its higher grade counterpart known as anaplastic oligodendroglioma. Detection of 1p/19q codeletion in gliomas is important because, together with another mutation in an enzyme known as isocitrate dehydrogenase, it is needed to make the diagnosis of an oligodendroglioma. Presence of 1p/19q codeletion also informs patient prognosis and prediction of the best drug treatment. The main two tests in use are fluorescent in situ hybridisation (FISH) and polymerase chain reaction (PCR)-based loss of heterozygosity (LOH) assays (also known as PCR-based short tandem repeat or microsatellite analysis). Many other tests are available. None of the tests is perfect, although PCR-based LOH is expected to have very high sensitivity. OBJECTIVES To estimate the sensitivity and specificity and cost-effectiveness of different deoxyribonucleic acid (DNA)-based techniques for determining 1p/19q codeletion status in glioma. SEARCH METHODS We searched MEDLINE, Embase and BIOSIS up to July 2019. There were no restrictions based on language or date of publication. We sought economic evaluation studies from the results of this search and using the National Health Service Economic Evaluation Database. SELECTION CRITERIA We included cross-sectional studies in adults with glioma or any subtype of glioma, presenting raw data or cross-tabulations of two or more DNA-based tests for 1p/19q codeletion. We also sought economic evaluations of these tests. DATA COLLECTION AND ANALYSIS We followed procedures outlined in the Cochrane Handbook for Diagnostic Test Accuracy Reviews. Two review authors independently screened titles/abstracts/full texts, performed data extraction, and undertook applicability and risk of bias assessments using QUADAS-2. Meta-analyses used the hierarchical summary ROC model to estimate and compare test accuracy. We used FISH and PCR-based LOH as alternate reference standards to examine how tests compared with those in common use, and conducted a latent class analysis comparing FISH and PCR-based LOH. We constructed an economic model to evaluate cost-effectiveness. MAIN RESULTS We included 53 studies examining: PCR-based LOH, FISH, single nucleotide polymorphism (SNP) array, next-generation sequencing (NGS), comparative genomic hybridisation (CGH), array comparative genomic hybridisation (aCGH), multiplex-ligation-dependent probe amplification (MLPA), real-time PCR, chromogenic in situ hybridisation (CISH), mass spectrometry (MS), restriction fragment length polymorphism (RFLP) analysis, G-banding, methylation array and NanoString. Risk of bias was low for only one study; most gave us concerns about how patients were selected or about missing data. We had applicability concerns about many of the studies because only patients with specific subtypes of glioma were included. 1520 participants contributed to analyses using FISH as the reference, 1304 participants to analyses involving PCR-based LOH as the reference and 262 participants to analyses of comparisons between methods from studies not including FISH or PCR-based LOH. Most evidence was available for comparison of FISH with PCR-based LOH (15 studies, 915 participants): PCR-based LOH detected 94% of FISH-determined codeletions (95% credible interval (CrI) 83% to 98%) and FISH detected 91% of codeletions determined by PCR-based LOH (CrI 78% to 97%). Of tumours determined not to have a deletion by FISH, 94% (CrI 87% to 98%) had a deletion detected by PCR-based LOH, and of those determined not to have a deletion by PCR-based LOH, 96% (CrI 90% to 99%) had a deletion detected by FISH. The latent class analysis suggested that PCR-based LOH may be slightly more accurate than FISH. Most other techniques appeared to have high sensitivity (i.e. produced few false-negative results) for detection of 1p/19q codeletion when either FISH or PCR-based LOH was considered as the reference standard, although there was limited evidence. There was some indication of differences in specificity (false-positive rate) with some techniques. Both NGS and SNP array had high specificity when considered against FISH as the reference standard (NGS: 6 studies, 243 participants; SNP: 6 studies, 111 participants), although we rated certainty in the evidence as low or very low. NGS and SNP array also had high specificity when PCR-based LOH was considered the reference standard, although with much more uncertainty as these results were based on fewer studies (just one study with 49 participants for NGS and two studies with 33 participants for SNP array). G-banding had low sensitivity and specificity when PCR-based LOH was the reference standard. Although MS had very high sensitivity and specificity when both FISH and PCR-based LOH were considered the reference standard, these results were based on only one study with a small number of participants. Real-time PCR also showed high specificity with FISH as a reference standard, although there were only two studies including 40 participants. We found no relevant economic evaluations. Our economic model using FISH as the reference standard suggested that the resource-optimising test depends on which measure of diagnostic accuracy is most important. With FISH as the reference standard, MLPA is likely to be cost-effective if society was willing to pay GBP 1000 or less for a true positive detected. However, as the value placed on a true positive increased, CISH was most cost-effective. Findings differed when the outcome measure changed to either true negative detected or correct diagnosis. When PCR-based LOH was used as the reference standard, MLPA was likely to be cost-effective for all measures of diagnostic accuracy at lower threshold values for willingness to pay. However, as the threshold values increased, none of the tests were clearly more likely to be considered cost-effective. AUTHORS' CONCLUSIONS In our review, most techniques (except G-banding) appeared to have good sensitivity (few false negatives) for detection of 1p/19q codeletions in glioma against both FISH and PCR-based LOH as a reference standard. However, we judged the certainty of the evidence low or very low for all the tests. There are possible differences in specificity, with both NGS and SNP array having high specificity (fewer false positives) for 1p/19q codeletion when considered against FISH as the reference standard. The economic analysis should be interpreted with caution due to the small number of studies.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne , UK
| | - Lena Schmidt
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire Kelly
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emmelyn Spencer Leal
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire L Faulkner
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Abigail Palmer
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Christopher Wragg
- Bristol Genetics Laboratory, Pathology Sciences, Southmead Hospital, Bristol, UK
| | - Sarah Jefferies
- Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - Sebastian Brandner
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Julian Pt Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kathreena M Kurian
- Bristol Medical School: Brain Tumour Research Centre, Public Health Sciences, University of Bristol, Bristol, UK
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21
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Sheppard AL, Elwenspoek MMC, Scott LJ, Corfield V, Everitt H, Gillett PM, Hay AD, Jones HE, Mallett S, Watson J, Whiting PF. Systematic review with meta-analysis: the accuracy of serological tests to support the diagnosis of coeliac disease. Aliment Pharmacol Ther 2022; 55:514-527. [PMID: 35043426 PMCID: PMC9305515 DOI: 10.1111/apt.16729] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/08/2021] [Accepted: 11/28/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND There is growing support for a biopsy avoidant approach to diagnose coeliac disease in both children and adults, using a serological diagnosis instead. AIMS To assess the diagnostic accuracy of serological tests for coeliac disease in adults and children. METHODS Seven electronic databases were searched between January 1990 and August 2020. Eligible diagnostic studies evaluated the accuracy of serological tests for coeliac disease against duodenal biopsy. Risk of bias assessment was performed using QUADAS-2. Bivariate random-effects meta-analyses were used to estimate serology sensitivity and specificity at the most commonly reported thresholds. RESULTS 113 studies (n = 28,338) were included, all in secondary care populations. A subset of studies were included in meta-analyses due to variations in diagnostic thresholds. Summary sensitivity and specificity of immunoglobulin A (IgA) anti-tissue transglutaminase were 90.7% (95% confidence interval: 87.3%, 93.2%) and 87.4% (84.4%, 90.0%) in adults (5 studies) and 97.7% (91.0%, 99.4%) and 70.2% (39.3%, 89.6%) in children (6 studies); and of IgA endomysial antibodies were 88.0% (75.2%, 94.7%) and 99.6% (92.3%, 100%) in adults (5 studies) and 94.5% (88.9%, 97.3%) and 93.8% (85.2%, 97.5%) in children (5 studies). CONCLUSIONS Anti-tissue transglutaminase sensitivity appears to be sufficient to rule out coeliac disease in children. The high specificity of endomysial antibody in adults supports its use to rule in coeliac disease. This evidence underpins the current development of clinical guidelines for a serological diagnosis of coeliac disease. Studies in primary care are needed to evaluate serological testing strategies in this setting.
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Affiliation(s)
- Athena L. Sheppard
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation TrustBristolUK
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Martha M. C. Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation TrustBristolUK
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Lauren J. Scott
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation TrustBristolUK
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Victoria Corfield
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hazel Everitt
- Primary Care Research CentreFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Peter M. Gillett
- Paediatric Gastroenterology DepartmentRoyal Hospital for Children and Young PeopleEdinburghUK
| | - Alastair D. Hay
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hayley E. Jones
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Susan Mallett
- Centre for Medical ImagingUniversity College LondonLondonUK
| | - Jessica Watson
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Penny F. Whiting
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
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22
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Clayton GL, Elliott D, Higgins JPT, Jones HE. Use of external evidence for design and Bayesian analysis of clinical trials: a qualitative study of trialists' views. Trials 2021; 22:789. [PMID: 34749778 PMCID: PMC8577005 DOI: 10.1186/s13063-021-05759-8] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence from previous studies is often used relatively informally in the design of clinical trials: for example, a systematic review to indicate whether a gap in the current evidence base justifies a new trial. External evidence can be used more formally in both trial design and analysis, by explicitly incorporating a synthesis of it in a Bayesian framework. However, it is unclear how common this is in practice or the extent to which it is considered controversial. In this qualitative study, we explored attitudes towards, and experiences of, trialists in incorporating synthesised external evidence through the Bayesian design or analysis of a trial. METHODS Semi-structured interviews were conducted with 16 trialists: 13 statisticians and three clinicians. Participants were recruited across several universities and trials units in the United Kingdom using snowball and purposeful sampling. Data were analysed using thematic analysis and techniques of constant comparison. RESULTS Trialists used existing evidence in many ways in trial design, for example, to justify a gap in the evidence base and inform parameters in sample size calculations. However, no one in our sample reported using such evidence in a Bayesian framework. Participants tended to equate Bayesian analysis with the incorporation of prior information on the intervention effect and were less aware of the potential to incorporate data on other parameters. When introduced to the concepts, many trialists felt they could be making more use of existing data to inform the design and analysis of a trial in particular scenarios. For example, some felt existing data could be used more formally to inform background adverse event rates, rather than relying on clinical opinion as to whether there are potential safety concerns. However, several barriers to implementing these methods in practice were identified, including concerns about the relevance of external data, acceptability of Bayesian methods, lack of confidence in Bayesian methods and software, and practical issues, such as difficulties accessing relevant data. CONCLUSIONS Despite trialists recognising that more formal use of external evidence could be advantageous over current approaches in some areas and useful as sensitivity analyses, there are still barriers to such use in practice.
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Affiliation(s)
- Gemma L Clayton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Daisy Elliott
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julian P T Higgins
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Hayley E Jones
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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23
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Yang B, Mallett S, Takwoingi Y, Davenport CF, Hyde CJ, Whiting PF, Deeks JJ, Leeflang MMG, Bossuyt PMM, Brazzelli MG, Dinnes J, Gurusamy KS, Jones HE, Lange S, Langendam MW, Macaskill P, McInnes MDF, Reitsma JB, Rutjes AWS, Sinclair A, de Vet HCW, Virgili G, Wade R, Westwood ME. QUADAS-C: A Tool for Assessing Risk of Bias in Comparative Diagnostic Accuracy Studies. Ann Intern Med 2021; 174:1592-1599. [PMID: 34698503 DOI: 10.7326/m21-2234] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Comparative diagnostic test accuracy studies assess and compare the accuracy of 2 or more tests in the same study. Although these studies have the potential to yield reliable evidence regarding comparative accuracy, shortcomings in the design, conduct, and analysis may bias their results. The currently recommended quality assessment tool for diagnostic test accuracy studies, QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2), is not designed for the assessment of test comparisons. The QUADAS-C (Quality Assessment of Diagnostic Accuracy Studies-Comparative) tool was developed as an extension of QUADAS-2 to assess the risk of bias in comparative diagnostic test accuracy studies. Through a 4-round Delphi study involving 24 international experts in test evaluation and a face-to-face consensus meeting, an initial version of the tool was developed that was revised and finalized following a pilot study among potential users. The QUADAS-C tool retains the same 4-domain structure of QUADAS-2 (Patient Selection, Index Test, Reference Standard, and Flow and Timing) and comprises additional questions to each QUADAS-2 domain. A risk-of-bias judgment for comparative accuracy requires a risk-of-bias judgment for the accuracy of each test (resulting from QUADAS-2) and additional criteria specific to test comparisons. Examples of such additional criteria include whether participants either received all index tests or were randomly assigned to index tests, and whether index tests were interpreted with blinding to the results of other index tests. The QUADAS-C tool will be useful for systematic reviews of diagnostic test accuracy addressing comparative questions. Furthermore, researchers may use this tool to identify and avoid risk of bias when designing a comparative diagnostic test accuracy study.
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Affiliation(s)
- Bada Yang
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands (B.Y., M.M.L.)
| | - Sue Mallett
- UCL Centre for Medical Imaging, University College London, London, United Kingdom (S.M.)
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, and National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, United Kingdom (Y.T., C.F.D., J.J.D.)
| | - Clare F Davenport
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, and National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, United Kingdom (Y.T., C.F.D., J.J.D.)
| | - Christopher J Hyde
- Exeter Test Group, The Institute of Health Research, College of Medicine and Health, University of Exeter, Exeter, United Kingdom (C.J.H.)
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom (P.F.W.)
| | - Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, and National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, United Kingdom (Y.T., C.F.D., J.J.D.)
| | - Mariska M G Leeflang
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands (B.Y., M.M.L.)
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24
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Elwenspoek MMC, Jackson J, O’Donnell R, Sinobas A, Dawson S, Everitt H, Gillett P, Hay AD, Lane DL, Mallett S, Robins G, Watson JC, Jones HE, Whiting P. The accuracy of diagnostic indicators for coeliac disease: A systematic review and meta-analysis. PLoS One 2021; 16:e0258501. [PMID: 34695139 PMCID: PMC8545431 DOI: 10.1371/journal.pone.0258501] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/28/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The prevalence of coeliac disease (CD) is around 1%, but diagnosis is challenged by varied presentation and non-specific symptoms and signs. This study aimed to identify diagnostic indicators that may help identify patients at a higher risk of CD in whom further testing is warranted. METHODS International guidance for systematic review methods were followed and the review was registered at PROSPERO (CRD42020170766). Six databases were searched until April 2021. Studies investigating diagnostic indicators, such as symptoms or risk conditions, in people with and without CD were eligible for inclusion. Risk of bias was assessed using the QUADAS-2 tool. Summary sensitivity, specificity, and positive predictive values were estimated for each diagnostic indicator by fitting bivariate random effects meta-analyses. FINDINGS 191 studies reporting on 26 diagnostic indicators were included in the meta-analyses. We found large variation in diagnostic accuracy estimates between studies and most studies were at high risk of bias. We found strong evidence that people with dermatitis herpetiformis, migraine, family history of CD, HLA DQ2/8 risk genotype, anaemia, type 1 diabetes, osteoporosis, or chronic liver disease are more likely than the general population to have CD. Symptoms, psoriasis, epilepsy, inflammatory bowel disease, systemic lupus erythematosus, fractures, type 2 diabetes, and multiple sclerosis showed poor diagnostic ability. A sensitivity analysis revealed a 3-fold higher risk of CD in first-degree relatives of CD patients. CONCLUSIONS Targeted testing of individuals with dermatitis herpetiformis, migraine, family history of CD, HLA DQ2/8 risk genotype, anaemia, type 1 diabetes, osteoporosis, or chronic liver disease could improve case-finding for CD, therefore expediting appropriate treatment and reducing adverse consequences. Migraine and chronic liver disease are not yet included as a risk factor in all CD guidelines, but it may be appropriate for these to be added. Future research should establish the diagnostic value of combining indicators.
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Affiliation(s)
- Martha M. C. Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Rachel O’Donnell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Anthony Sinobas
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sarah Dawson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Hazel Everitt
- Primary Care Research Centre, University of Southampton, Southampton, United Kingdom
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Alastair D. Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Susan Mallett
- Centre for Medical Imaging, University College London, London, United Kingdom
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Jessica C. Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Hayley E. Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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25
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Harrison S, Dixon P, Jones HE, Davies AR, Howe LD, Davies NM. Long-term cost-effectiveness of interventions for obesity: A mendelian randomisation study. PLoS Med 2021; 18:e1003725. [PMID: 34449774 PMCID: PMC8437285 DOI: 10.1371/journal.pmed.1003725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/13/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The prevalence of obesity has increased in the United Kingdom, and reliably measuring the impact on quality of life and the total healthcare cost from obesity is key to informing the cost-effectiveness of interventions that target obesity, and determining healthcare funding. Current methods for estimating cost-effectiveness of interventions for obesity may be subject to confounding and reverse causation. The aim of this study is to apply a new approach using mendelian randomisation for estimating the cost-effectiveness of interventions that target body mass index (BMI), which may be less affected by confounding and reverse causation than previous approaches. METHODS AND FINDINGS We estimated health-related quality-adjusted life years (QALYs) and both primary and secondary healthcare costs for 310,913 men and women of white British ancestry aged between 39 and 72 years in UK Biobank between recruitment (2006 to 2010) and 31 March 2017. We then estimated the causal effect of differences in BMI on QALYs and total healthcare costs using mendelian randomisation. For this, we used instrumental variable regression with a polygenic risk score (PRS) for BMI, derived using a genome-wide association study (GWAS) of BMI, with age, sex, recruitment centre, and 40 genetic principal components as covariables to estimate the effect of a unit increase in BMI on QALYs and total healthcare costs. Finally, we used simulations to estimate the likely effect on BMI of policy relevant interventions for BMI, then used the mendelian randomisation estimates to estimate the cost-effectiveness of these interventions. A unit increase in BMI decreased QALYs by 0.65% of a QALY (95% confidence interval [CI]: 0.49% to 0.81%) per year and increased annual total healthcare costs by £42.23 (95% CI: £32.95 to £51.51) per person. When considering only health conditions usually considered in previous cost-effectiveness modelling studies (cancer, cardiovascular disease, cerebrovascular disease, and type 2 diabetes), we estimated that a unit increase in BMI decreased QALYs by only 0.16% of a QALY (95% CI: 0.10% to 0.22%) per year. We estimated that both laparoscopic bariatric surgery among individuals with BMI greater than 35 kg/m2, and restricting volume promotions for high fat, salt, and sugar products, would increase QALYs and decrease total healthcare costs, with net monetary benefits (at £20,000 per QALY) of £13,936 (95% CI: £8,112 to £20,658) per person over 20 years, and £546 million (95% CI: £435 million to £671 million) in total per year, respectively. The main limitations of this approach are that mendelian randomisation relies on assumptions that cannot be proven, including the absence of directional pleiotropy, and that genotypes are independent of confounders. CONCLUSIONS Mendelian randomisation can be used to estimate the impact of interventions on quality of life and healthcare costs. We observed that the effect of increasing BMI on health-related quality of life is much larger when accounting for 240 chronic health conditions, compared with only a limited selection. This means that previous cost-effectiveness studies have likely underestimated the effect of BMI on quality of life and, therefore, the potential cost-effectiveness of interventions to reduce BMI.
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Affiliation(s)
- Sean Harrison
- MRC Integrative Epidemiology Unit (IEU), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- * E-mail:
| | - Padraig Dixon
- MRC Integrative Epidemiology Unit (IEU), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Hayley E. Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Alisha R. Davies
- Research and Evaluation Division, Public Health Wales NHS Trust, Cardiff, United Kingdom
| | - Laura D. Howe
- MRC Integrative Epidemiology Unit (IEU), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Neil M. Davies
- MRC Integrative Epidemiology Unit (IEU), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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26
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Jones HE. Correction: Quantifying how diagnostic test accuracy depends on threshold in a meta-analysis. Stat Med 2021; 40:4166. [PMID: 34120359 DOI: 10.1002/sim.9103] [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] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol Medical School, Bristol, UK
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27
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Jones HE, Mulchandani R, Taylor-Phillips S, Ades AE, Shute J, Perry KR, Chandra NL, Brooks T, Charlett A, Hickman M, Oliver I, Kaptoge S, Danesh J, Di Angelantonio E, Wyllie D. Accuracy of four lateral flow immunoassays for anti SARS-CoV-2 antibodies: a head-to-head comparative study. EBioMedicine 2021; 68:103414. [PMID: 34098341 PMCID: PMC8176919 DOI: 10.1016/j.ebiom.2021.103414] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND SARS-CoV-2 antibody tests are used for population surveillance and might have a future role in individual risk assessment. Lateral flow immunoassays (LFIAs) can deliver results rapidly and at scale, but have widely varying accuracy. METHODS In a laboratory setting, we performed head-to-head comparisons of four LFIAs: the Rapid Test Consortium's AbC-19TM Rapid Test, OrientGene COVID IgG/IgM Rapid Test Cassette, SureScreen COVID-19 Rapid Test Cassette, and Biomerica COVID-19 IgG/IgM Rapid Test. We analysed blood samples from 2,847 key workers and 1,995 pre-pandemic blood donors with all four devices. FINDINGS We observed a clear trade-off between sensitivity and specificity: the IgG band of the SureScreen device and the AbC-19TM device had higher specificities but OrientGene and Biomerica higher sensitivities. Based on analysis of pre-pandemic samples, SureScreen IgG band had the highest specificity (98.9%, 95% confidence interval 98.3 to 99.3%), which translated to the highest positive predictive value across any pre-test probability: for example, 95.1% (95% uncertainty interval 92.6, 96.8%) at 20% pre-test probability. All four devices showed higher sensitivity at higher antibody concentrations ("spectrum effects"), but the extent of this varied by device. INTERPRETATION The estimates of sensitivity and specificity can be used to adjust for test error rates when using these devices to estimate the prevalence of antibody. If tests were used to determine whether an individual has SARS-CoV-2 antibodies, in an example scenario in which 20% of individuals have antibodies we estimate around 5% of positive results on the most specific device would be false positives. FUNDING Public Health England.
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Affiliation(s)
- Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, UK.
| | | | | | - A E Ades
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | | | | | | | | | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, UK
| | - Isabel Oliver
- NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, UK; Public Health England, UK
| | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, UK
| | - John Danesh
- Department of Public Health and Primary Care, University of Cambridge, UK
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28
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Dipper A, Jones HE, Bhatnagar R, Preston NJ, Maskell N, Clive A. Interventions for the management of malignant pleural effusions: an updated network meta-analysis. Eur Respir Rev 2021; 30:30/160/210025. [PMID: 33952602 DOI: 10.1183/16000617.0025-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Alex Dipper
- University of Bristol Academic Respiratory Unit, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rahul Bhatnagar
- University of Bristol Academic Respiratory Unit, Bristol, UK
| | - Nancy J Preston
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Nick Maskell
- University of Bristol Academic Respiratory Unit, Bristol, UK
| | - Amelia Clive
- North Bristol NHS Trust, Southmead Hospital, Bristol, UK
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Mulchandani R, Taylor-Philips S, Jones HE, Ades AE, Borrow R, Linley E, Kirwan PD, Stewart R, Moore P, Boyes J, Hormis A, Todd N, Colda A, Reckless I, Brooks T, Charlett A, Hickman M, Oliver I, Wyllie D. Association between self-reported signs and symptoms and SARS-CoV-2 antibody detection in UK key workers. J Infect 2021; 82:151-161. [PMID: 33775704 PMCID: PMC7997203 DOI: 10.1016/j.jinf.2021.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/16/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Screening for SARS-CoV-2 antibodies is under way in some key worker groups; how this adds to self-reported COVID-19 illness is unclear. In this study, we investigate the association between self-reported belief of COVID-19 illness and seropositivity. METHODS Cross-sectional study of three key worker streams comprising (A) Police and Fire & Rescue (2 sites) (B) healthcare workers (1 site) and (C) healthcare workers with previously positive PCR result (5 sites). We collected self-reported signs and symptoms of COVID-19 and compared this with serology results from two SARS-CoV-2 immunoassays (Roche Elecsys® and EUROIMMUN). RESULTS Between 01 and 26 June, we recruited 2847 individuals (Stream A: 1,247, Stream B: 1,546 and Stream C: 154). Amongst those without previous positive PCR tests, 687/2,579 (26%) reported belief they had COVID-19, having experienced compatible symptoms; however, only 208 (30.3%) of these were seropositive on both immunoassays. Both immunoassays had high sensitivities relative to previous PCR positivity (>93%); there was also limited decline in antibody titres up to 110 days post symptom onset. Symptomatic but seronegative individuals had differing symptom profiles and shorter illnesses than seropositive individuals. CONCLUSION Non-COVID-19 respiratory illness may have been mistaken for COVID-19 during the outbreak; laboratory testing is more specific than self-reported key worker beliefs in ascertaining past COVID-19 disease.
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Affiliation(s)
- Ranya Mulchandani
- UK Field Epidemiology Training Programme (FETP), Public Health England, London, United Kingdom; Field Service, Midlands, National Infection Service, Public Health England, Birmingham, United Kingdom
| | | | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - A E Ades
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Ray Borrow
- Seroepidemiology Unit (SEU), Manchester Royal Infirmary, Public Health England, Manchester, United Kingdom
| | - Ezra Linley
- Seroepidemiology Unit (SEU), Manchester Royal Infirmary, Public Health England, Manchester, United Kingdom
| | - Peter D Kirwan
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Richard Stewart
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
| | - Philippa Moore
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - John Boyes
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Anil Hormis
- The Rotherham NHS Foundation Trust, Rotherham, United Kingdom
| | - Neil Todd
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Antoanela Colda
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
| | - Ian Reckless
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
| | - Tim Brooks
- Rare and Imported Pathogens Laboratory (RIPL), Porton Down, Public Health England, Salisbury, United Kingdom
| | - Andre Charlett
- Statistical Unit, Public Health England, London, United Kingdom
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Isabel Oliver
- NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom; National Infection Service, Public Health England, Bristol, United Kingdom
| | - David Wyllie
- Field Service, East of England, National Infection Service, Public Health England, Cambridge, United Kingdom; NIHR Health Protection Research Unit (HPRU) in Genomics and Data Enabling, University of Warwick, Warwick, United Kingdom.
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Zapf A, Albert C, Frömke C, Haase M, Hoyer A, Jones HE, Rücker G. Meta-analysis of diagnostic accuracy studies with multiple thresholds: Comparison of different approaches. Biom J 2021; 63:699-711. [PMID: 33475187 DOI: 10.1002/bimj.202000091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 10/14/2020] [Accepted: 10/24/2020] [Indexed: 01/03/2023]
Abstract
Methods for standard meta-analysis of diagnostic test accuracy studies are well established and understood. For the more complex case in which studies report test accuracy across multiple thresholds, several approaches have recently been proposed. These are based on similar ideas, but make different assumptions. In this article, we apply four different approaches to data from a recent systematic review in the area of nephrology and compare the results. The four approaches use: a linear mixed effects model, a Bayesian multinomial random effects model, a time-to-event model and a nonparametric model, respectively. In the case study data, the accuracy of neutrophil gelatinase-associated lipocalin for the diagnosis of acute kidney injury was assessed in different scenarios, with sensitivity and specificity estimates available for three thresholds in each primary study. All approaches led to plausible and mostly similar summary results. However, we found considerable differences in results for some scenarios, for example, differences in the area under the receiver operating characteristic curve (AUC) of up to 0.13. The Bayesian approach tended to lead to the highest values of the AUC, and the nonparametric approach tended to produce the lowest values across the different scenarios. Though we recommend using these approaches, our findings motivate the need for a simulation study to explore optimal choice of method in various scenarios.
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Affiliation(s)
- Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Albert
- Faculty of Medicine, Otto-von-Guericke University, Magdeburg, Germany.,Diaverum Renal Services Germany, MVZ Am Neuen Garten, Potsdam, Germany
| | - Cornelia Frömke
- Department of Information and Communication, Faculty for Media, Information and Design, University of Applied Sciences and Arts Hannover, Hannover, Germany
| | - Michael Haase
- Faculty of Medicine, Otto-von-Guericke University, Magdeburg, Germany.,Diaverum Renal Services Germany, MVZ Am Neuen Garten, Potsdam, Germany
| | - Annika Hoyer
- Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
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Jones HE, Harris RJ, Downing BC, Pierce M, Millar T, Ades AE, Welton NJ, Presanis AM, Angelis DD, Hickman M. Estimating the prevalence of problem drug use from drug-related mortality data. Addiction 2020; 115:2393-2404. [PMID: 32392631 PMCID: PMC7613965 DOI: 10.1111/add.15111] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 08/21/2019] [Revised: 11/05/2019] [Accepted: 05/04/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Indirect estimation methods are required for estimating the size of populations where only a proportion of individuals are observed directly, such as problem drug users (PDUs). Capture-recapture and multiplier methods are widely used, but have been criticized as subject to bias. We propose a new approach to estimating prevalence of PDU from numbers of fatal drug-related poisonings (fDRPs) using linked databases, addressing the key limitations of simplistic 'mortality multipliers'. METHODS Our approach requires linkage of data on a large cohort of known PDUs to mortality registers and summary information concerning additional fDRPs observed outside this cohort. We model fDRP rates among the cohort and assume that rates in unobserved PDUs are equal to rates in the cohort during periods out of treatment. Prevalence is estimated in a Bayesian statistical framework, in which we simultaneously fit regression models to fDRP rates and prevalence, allowing both to vary by demographic factors and the former also by treatment status. RESULTS We report a case study analysis, estimating the prevalence of opioid dependence in England in 2008/09, by gender, age group and geographical region. Overall prevalence was estimated as 0.82% (95% credible interval = 0.74-0.94%) of 15-64-year-olds, which is similar to a published estimate based on capture-recapture analysis. CONCLUSIONS Our modelling approach estimates prevalence from drug-related mortality data, while addressing the main limitations of simplistic multipliers. This offers an alternative approach for the common situation where available data sources do not meet the strong assumptions required for valid capture-recapture estimation. In a case study analysis, prevalence estimates based on our approach were surprisingly similar to existing capture-recapture estimates but, we argue, are based on a much more objective and justifiable modelling approach.
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Affiliation(s)
- Hayley E. Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ross J. Harris
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Beatrice C. Downing
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthias Pierce
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Tim Millar
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - A. E. Ades
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J. Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Daniela De Angelis
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK,MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Mulchandani R, Jones HE, Taylor-Phillips S, Shute J, Perry K, Jamarani S, Brooks T, Charlett A, Hickman M, Oliver I, Kaptoge S, Danesh J, Di Angelantonio E, Ades AE, Wyllie DH. Accuracy of UK Rapid Test Consortium (UK-RTC) "AbC-19 Rapid Test" for detection of previous SARS-CoV-2 infection in key workers: test accuracy study. BMJ 2020; 371:m4262. [PMID: 33177070 PMCID: PMC7656121 DOI: 10.1136/bmj.m4262] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To assess the accuracy of the AbC-19 Rapid Test lateral flow immunoassay for the detection of previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN Test accuracy study. SETTING Laboratory based evaluation. PARTICIPANTS 2847 key workers (healthcare staff, fire and rescue officers, and police officers) in England in June 2020 (268 with a previous polymerase chain reaction (PCR) positive result (median 63 days previously), 2579 with unknown previous infection status); and 1995 pre-pandemic blood donors. MAIN OUTCOME MEASURES AbC-19 sensitivity and specificity, estimated using known negative (pre-pandemic) and known positive (PCR confirmed) samples as reference standards and secondly using the Roche Elecsys anti-nucleoprotein assay, a highly sensitive laboratory immunoassay, as a reference standard in samples from key workers. RESULTS Test result bands were often weak, with positive/negative discordance by three trained laboratory staff for 3.9% of devices. Using consensus readings, for known positive and negative samples sensitivity was 92.5% (95% confidence interval 88.8% to 95.1%) and specificity was 97.9% (97.2% to 98.4%). Using an immunoassay reference standard, sensitivity was 94.2% (90.7% to 96.5%) among PCR confirmed cases but 84.7% (80.6% to 88.1%) among other people with antibodies. This is consistent with AbC-19 being more sensitive when antibody concentrations are higher, as people with PCR confirmation tended to have more severe disease whereas only 62% (218/354) of seropositive participants had had symptoms. If 1 million key workers were tested with AbC-19 and 10% had actually been previously infected, 84 700 true positive and 18 900 false positive results would be projected. The probability that a positive result was correct would be 81.7% (76.8% to 85.8%). CONCLUSIONS AbC-19 sensitivity was lower among unselected populations than among PCR confirmed cases of SARS-CoV-2, highlighting the scope for overestimation of assay performance in studies involving only PCR confirmed cases, owing to "spectrum bias." Assuming that 10% of the tested population have had SARS-CoV-2 infection, around one in five key workers testing positive with AbC-19 would be false positives. STUDY REGISTRATION ISRCTN 56609224.
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Elwenspoek MMC, Jackson J, Dawson S, Everitt H, Gillett P, Hay AD, Jones HE, Lane DL, Mallett S, Robins G, Sheppard AL, Stubbs J, Thom H, Watson J, Whiting P. Accuracy of potential diagnostic indicators for coeliac disease: a systematic review protocol. BMJ Open 2020; 10:e038994. [PMID: 33020103 PMCID: PMC7537462 DOI: 10.1136/bmjopen-2020-038994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Coeliac disease (CD) is a systemic immune-mediated disorder triggered by gluten in genetically predisposed individuals. CD is diagnosed using a combination of serology tests and endoscopic biopsy of the small intestine. However, because of non-specific symptoms and heterogeneous clinical presentation, diagnosing CD is challenging. Early detection of CD through improved case-finding strategies can improve the response to a gluten-free diet, patients' quality of life and potentially reduce the risk of complications. However, there is a lack of consensus in which groups may benefit from active case-finding. METHODS AND ANALYSIS We will perform a systematic review to determine the accuracy of diagnostic indicators (such as symptoms and risk factors) for CD in adults and children, and thus can help identify patients who should be offered CD testing. MEDLINE, Embase, Cochrane Library and Web of Science will be searched from 1997 until 2020. Screening will be performed in duplicate. Data extraction will be performed by one and checked by a second reviewer. Disagreements will be resolved through discussion or referral to a third reviewer. We will produce a narrative summary of identified prediction models. Studies, where 2×2 data can be extracted or reconstructed, will be treated as diagnostic accuracy studies, that is, the diagnostic indicators are the index tests and CD serology and/or biopsy is the reference standard. For each diagnostic indicator, we will perform a bivariate random-effects meta-analysis of the sensitivity and specificity. ETHICS AND DISSEMINATION Results will be reported in peer-reviewed journals, academic and public presentations and social media. We will convene an implementation panel to advise on the optimum strategy for enhanced dissemination. We will discuss findings with Coeliac UK to help with dissemination to patients. Ethical approval is not applicable, as this is a systematic review and no research participants will be involved. PROSPERO REGISTRATION NUMBER CRD42020170766.
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Affiliation(s)
- Martha Maria Christine Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hazel Everitt
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Susan Mallett
- School of Health and Population Sciences, University of Birmingham, Birmingham, West Midlands, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
| | | | - Jo Stubbs
- Patient representative, Patient representative, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Harrison S, Davies AR, Dickson M, Tyrrell J, Green MJ, Katikireddi SV, Campbell D, Munafò M, Dixon P, Jones HE, Rice F, Davies NM, Howe LD. The causal effects of health conditions and risk factors on social and socioeconomic outcomes: Mendelian randomization in UK Biobank. Int J Epidemiol 2020; 49:1661-1681. [PMID: 32808034 PMCID: PMC7746412 DOI: 10.1093/ije/dyaa114] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We aimed to estimate the causal effect of health conditions and risk factors on social and socioeconomic outcomes in UK Biobank. Evidence on socioeconomic impacts is important to understand because it can help governments, policy makers and decision makers allocate resources efficiently and effectively. METHODS We used Mendelian randomization to estimate the causal effects of eight health conditions (asthma, breast cancer, coronary heart disease, depression, eczema, migraine, osteoarthritis, type 2 diabetes) and five health risk factors [alcohol intake, body mass index (BMI), cholesterol, systolic blood pressure, smoking] on 19 social and socioeconomic outcomes in 336 997 men and women of White British ancestry in UK Biobank, aged between 39 and 72 years. Outcomes included annual household income, employment, deprivation [measured by the Townsend deprivation index (TDI)], degree-level education, happiness, loneliness and 13 other social and socioeconomic outcomes. RESULTS Results suggested that BMI, smoking and alcohol intake affect many socioeconomic outcomes. For example, smoking was estimated to reduce household income [mean difference = -£22 838, 95% confidence interval (CI): -£31 354 to -£14 321] and the chance of owning accommodation [absolute percentage change (APC) = -20.8%, 95% CI: -28.2% to -13.4%], of being satisfied with health (APC = -35.4%, 95% CI: -51.2% to -19.5%) and of obtaining a university degree (APC = -65.9%, 95% CI: -81.4% to -50.4%), while also increasing deprivation (mean difference in TDI = 1.73, 95% CI: 1.02 to 2.44, approximately 216% of a decile of TDI). There was evidence that asthma decreased household income, the chance of obtaining a university degree and the chance of cohabiting, and migraine reduced the chance of having a weekly leisure or social activity, especially in men. For other associations, estimates were null. CONCLUSIONS Higher BMI, alcohol intake and smoking were all estimated to adversely affect multiple social and socioeconomic outcomes. Effects were not detected between health conditions and socioeconomic outcomes using Mendelian randomization, with the exceptions of depression, asthma and migraines. This may reflect true null associations, selection bias given the relative health and age of participants in UK Biobank, and/or lack of power to detect effects.
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Affiliation(s)
- Sean Harrison
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alisha R Davies
- Research and Evaluation Division, Public Health Wales NHS Trust, Cardiff, UK
| | - Matt Dickson
- Institute for Policy Research, University of Bath, Bath, UK
| | - Jessica Tyrrell
- University of Exeter Medical School, RILD Building, RD&E Hospital Wonford, Exeter, UK
| | - Michael J Green
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | | | - Desmond Campbell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Marcus Munafò
- UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, UK
| | - Padraig Dixon
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Frances Rice
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Neil M Davies
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Norway
| | - Laura D Howe
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Benedetti A, Levis B, Rücker G, Jones HE, Schumacher M, Ioannidis JPA, Thombs B. An empirical comparison of three methods for multiple cutoff diagnostic test meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool using published data vs individual level data. Res Synth Methods 2020; 11:833-848. [PMID: 32896096 DOI: 10.1002/jrsm.1443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/05/2019] [Revised: 07/10/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022]
Abstract
Selective cutoff reporting in primary diagnostic accuracy studies with continuous or ordinal data may result in biased estimates when meta-analyzing studies. Collecting individual participant data (IPD) and estimating accuracy across all relevant cutoffs for all studies can overcome such bias but is labour intensive. We meta-analyzed the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. We compared results for two statistical methods proposed by Steinhauser and by Jones to account for missing cutoffs, with results from a series of bivariate random effects models (BRM) estimated separately at each cutoff. We applied the methods to a dataset that contained information only on cutoffs that were reported in the primary publications and to the full IPD dataset that contained information for all cutoffs for every study. For each method, we estimated pooled sensitivity and specificity and associated 95% confidence intervals for each cutoff and area under the curve (AUC). The full IPD dataset comprised data from 45 studies, 15 020 subjects, and 1972 cases of major depression and included information on every possible cutoff. When using data available in publications, using statistical approaches outperformed the BRM applied to the same data. AUC was similar for all approaches when using the full IPD dataset, though pooled estimates were slightly different. Overall, using statistical methods to fill in missing cutoff data recovered the receiver operating characteristic (ROC) curve from the full IPD dataset well when using only the published subset. All methods performed similarly when applied to the full IPD dataset.
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Affiliation(s)
- Andrea Benedetti
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Canada.,Centre for Outcomes Research and Evaluation, McGill University Health Centre, Canada
| | - Brooke Levis
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Canada.,Lady Davis Research Institute, SMBD Jewish General Hospital, Canada
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Germany
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Martin Schumacher
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Germany
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), and Departments of Medicine, Health Research and Policy, Biomedical Data Science, and Statistics, Stanford University, Stanford, California, USA
| | - Brett Thombs
- Lady Davis Research Institute, SMBD Jewish General Hospital, Canada
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Turner RM, Rhodes KM, Jones HE, Higgins JPT, Haskins JA, Whiting PF, Hróbjartsson A, Caldwell DM, Morris RW, Reeves BC, Worthington HV, Boutron I, Savović J. Agreement was moderate between data-based and opinion-based assessments of biases affecting randomized trials within meta-analyses. J Clin Epidemiol 2020; 125:16-25. [PMID: 32416338 PMCID: PMC7482431 DOI: 10.1016/j.jclinepi.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 04/24/2020] [Accepted: 05/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Randomized trials included in meta-analyses are often affected by bias caused by methodological flaws or limitations, but the degree of bias is unknown. Two proposed methods adjust the trial results for bias using empirical evidence from published meta-epidemiological studies or expert opinion. METHODS We investigated agreement between data-based and opinion-based approaches to assessing bias in each of four domains: sequence generation, allocation concealment, blinding, and incomplete outcome data. From each sampled meta-analysis, a pair of trials with the highest and lowest empirical model-based bias estimates was selected. Independent assessors were asked which trial within each pair was judged more biased on the basis of detailed trial design summaries. RESULTS Assessors judged trials to be equally biased in 68% of pairs evaluated. When assessors judged one trial as more biased, the proportion of judgments agreeing with the model-based ranking was highest for allocation concealment (79%) and blinding (79%) and lower for sequence generation (59%) and incomplete outcome data (56%). CONCLUSION Most trial pairs found to be discrepant empirically were judged to be equally biased by assessors. We found moderate agreement between opinion and data-based evidence in pairs where assessors ranked one trial as more biased.
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Affiliation(s)
- Rebecca M Turner
- MRC Clinical Trials Unit, University College London, London, UK; MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Kirsty M Rhodes
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Statistical Innovation, Oncology Biometrics, AstraZeneca, Cambridge, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica A Haskins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Deborah M Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard W Morris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Isabelle Boutron
- Centre d'Épidémiologie Clinique, Hôpital Hôtel-Dieu, Assistance Publique Hôpitaux de Paris, Paris, France; Team METHODS, Centre of Research in Epidemiology and Statistics-CRESS Inserm UMR1153, Paris, France; Université Paris Descartes, Paris, France
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; NIHR Applied Research Collaboration (ARC) West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Nunn AC, Jones HE, Morosanu CO, Singleton WGB, Williams MA, Nagel SJ, Luciano MG, Zwimpfer TJ, Holubkov R, Wisoff JH, McKhann GM, Hamilton MG, Edwards RJ. Extended lumbar drainage in idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis of diagnostic test accuracy. Br J Neurosurg 2020; 35:285-291. [PMID: 32643967 DOI: 10.1080/02688697.2020.1787948] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND When appropriately selected, a high proportion of patients with suspected idiopathic normal pressure hydrocephalus (iNPH) will respond to cerebrospinal fluid diversion with a shunt. Extended lumbar drainage (ELD) is regarded as the most accurate test for this condition, however, varying estimates of its accuracy are found in the current literature. Here, we review the literature in order to provide summary estimates of sensitivity, specificity, positive- and negative predictive value for this test through meta-analysis of suitably rigorous studies. METHODS Studies involving a population of NPH patients with predominantly idiopathic aetiology (>80%) in which the intention of the study was to shunt patients regardless of the outcome of ELD were included in the review. Various literature databases were searched to identify diagnostic test accuracy studies addressing ELD in the diagnosis of iNPH. Those studies passing screening and eligibility were assessed using the QUADAS-2 tool and data extracted for bivariate random effects meta-analysis. RESULTS Four small studies were identified. They showed disparate results concerning diagnostic test accuracy. The summary estimates for sensitivity and specificity were 94% (CI 41-100%) and 85% (CI 33-100%), respectively. The summary estimates of positive and negative predictive value were both 90% (CIs 65-100% and 48-100%, respectively). CONCLUSION Large, rigorous studies addressing the diagnostic accuracy of ELD are lacking, and little robust evidence exists to support the use of ELD in diagnostic algorithms for iNPH. Therefore, a large cohort study, or ideally an RCT, is needed to determine best practice in selecting patients for shunt surgery.
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Affiliation(s)
- Adam C Nunn
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Michael A Williams
- Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA.,Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA
| | - Sean J Nagel
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Mark G Luciano
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thomas J Zwimpfer
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Richard Holubkov
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jeffrey H Wisoff
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital at NYU Langone Health, New York, NY, USA
| | - Guy M McKhann
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Neurological Surgery, Columbia University School of Medicine, New York, NY, USA
| | - Mark G Hamilton
- Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA.,Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary School of Medicine, Calgary, Canada
| | - Richard J Edwards
- Department of Neurosurgery, Southmead Hospital, Bristol, UK.,Adult Hydrocephalus Clinical Research Network, Hydrocephalus Association, Bethesda, MD, USA
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Harrison S, Tilling K, Turner EL, Martin RM, Lennon R, Lane JA, Donovan JL, Hamdy FC, Neal DE, Bosch JLHR, Jones HE. Systematic review and meta-analysis of the associations between body mass index, prostate cancer, advanced prostate cancer, and prostate-specific antigen. Cancer Causes Control 2020; 31:431-449. [PMID: 32162172 PMCID: PMC7105428 DOI: 10.1007/s10552-020-01291-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/27/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE The relationship between body mass index (BMI) and prostate cancer remains unclear. However, there is an inverse association between BMI and prostate-specific antigen (PSA), used for prostate cancer screening. We conducted this review to estimate the associations between BMI and (1) prostate cancer, (2) advanced prostate cancer, and (3) PSA. METHODS We searched PubMed and Embase for studies until 02 October 2017 and obtained individual participant data from four studies. In total, 78 studies were identified for the association between BMI and prostate cancer, 21 for BMI and advanced prostate cancer, and 35 for BMI and PSA. We performed random-effects meta-analysis of linear associations of log-PSA and prostate cancer with BMI and, to examine potential non-linearity, of associations between categories of BMI and each outcome. RESULTS In the meta-analyses with continuous BMI, a 5 kg/m2 increase in BMI was associated with a percentage change in PSA of - 5.88% (95% CI - 6.87 to - 4.87). Using BMI categories, compared to normal weight men the PSA levels of overweight men were 3.43% lower (95% CI - 5.57 to - 1.23), and obese men were 12.9% lower (95% CI - 15.2 to - 10.7). Prostate cancer and advanced prostate cancer analyses showed little or no evidence associations. CONCLUSION There is little or no evidence of an association between BMI and risk of prostate cancer or advanced prostate cancer, and strong evidence of an inverse and non-linear association between BMI and PSA. The association between BMI and prostate cancer is likely biased if missed diagnoses are not considered.
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Affiliation(s)
- Sean Harrison
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England.
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, England.
| | - Kate Tilling
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, England
| | - Emma L Turner
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Richard M Martin
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, England
| | - Rosie Lennon
- Department of Environment and Geography, University of York, York, England
| | - J Athene Lane
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, England
| | - Jenny L Donovan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol NHS Trust, Bristol, England
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, England
| | - David E Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, England
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
| | - J L H Ruud Bosch
- Department of Urology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Hayley E Jones
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common problem for people with cancer and usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid, including administration of a pleurodesis agent (via a chest tube or thoracoscopy) or placement of an indwelling pleural catheter (IPC). This is an update of a review published in Issue 5, 2016, which replaced the original, published in 2004. OBJECTIVES To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success and to quantify differences in patient-reported outcomes and adverse effects between interventions. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and three other databases to June 2019. We screened reference lists from other relevant publications and searched trial registries. SELECTION CRITERIA We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE, comparing types of sclerosant, mode of administration and IPC use. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study design, characteristics, outcome measures, potential effect modifiers and risk of bias. The primary outcome was pleurodesis failure rate. Secondary outcomes were adverse events, patient-reported breathlessness control, quality of life, cost, mortality, survival, duration of inpatient stay and patient acceptability. We performed network meta-analyses of primary outcome data and secondary outcomes with enough data. We also performed pair-wise meta-analyses of direct comparison data. If we deemed interventions not jointly randomisable, or we found insufficient available data, we reported results by narrative synthesis. For the primary outcome, we performed sensitivity analyses to explore potential causes of heterogeneity and to evaluate pleurodesis agents administered via a chest tube only. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We identified 80 randomised trials (18 new), including 5507 participants. We found all except three studies at high or unclear risk of bias for at least one domain. Due to the nature of the interventions, most studies were unblinded. Pleurodesis failure rate We included 55 studies of 21 interventions in the primary network meta-analysis. We estimated the rank of each intervention's effectiveness. Talc slurry (ranked 6, 95% credible interval (Cr-I) 3 to 10) is an effective pleurodesis agent (moderate certainty for comparison with placebo) and may result in fewer pleurodesis failures than bleomycin and doxycycline (bleomycin versus talc slurry: odds ratio (OR) 2.24, 95% Cr-I 1.10 to 4.68; low certainty; ranked 11, 95% Cr-I 7 to 15; doxycycline versus talc slurry: OR 2.51, 95% Cr-I 0.81 to 8.40; low certainty; ranked 12, 95% Cr-I 5 to 18). There is little evidence of a difference between the pleurodesis failure rate of talc poudrage and talc slurry (OR 0.50, 95% Cr-I 0.21 to 1.02; moderate certainty). Evidence for any difference was further reduced when restricting analysis to studies at low risk of bias (defined as maximum one high risk domain in the risk of bias assessment) (pleurodesis failure talc poudrage versus talc slurry: OR 0.78, 95% Cr-I 0.16 to 2.08). IPCs without daily drainage are probably less effective at obtaining a definitive pleurodesis (cessation of pleural fluid drainage facilitating IPC removal) than talc slurry (OR 7.60, 95% Cr-I 2.96 to 20.47; rank = 18/21, 95% Cr-I 13 to 21; moderate certainty). Daily IPC drainage or instillation of talc slurry via IPC are likely to reduce pleurodesis failure rates. Adverse effects Adverse effects were inconsistently reported. We performed network meta-analyses for the risk of procedure-related fever and pain. The evidence for risk of developing fever was of low certainty, but suggested there may be little difference between interventions relative to talc slurry (talc poudrage: OR 0.89, 95% Cr-I 0.11 to 6.67; bleomycin: OR 2.33, 95% Cr-I 0.45 to 12.50; IPCs: OR 0.41, 95% Cr-I 0.00 to 50.00; doxycycline: OR 0.85, 95% Cr-I 0.05 to 14.29). Evidence also suggested there may be little difference between interventions in the risk of developing procedure-related pain, relative to talc slurry (talc poudrage: OR 1.26, 95% Cr-I 0.45 to 6.04; very-low certainty; bleomycin: OR 2.85, 95% Cr-I 0.78 to 11.53; low certainty; IPCs: OR 1.30, 95% Cr-I 0.29 to 5.87; low certainty; doxycycline: OR 3.35, 95% Cr-I 0.64 to 19.72; low certainty). Patient-reported control of breathlessness Pair-wise meta-analysis suggests there is likely no difference in breathlessness control, relative to talc slurry, of talc poudrage ((mean difference (MD) 4.00 mm, 95% CI -6.26 to 14.26) on a 100 mm visual analogue scale for breathlessness; studies = 1; participants = 184; moderate certainty) and IPCs without daily drainage (MD -6.12 mm, 95% CI -16.32 to 4.08; studies = 2; participants = 160; low certainty). Overall mortality There may be little difference between interventions when compared to talc slurry (bleomycin and IPC without daily drainage; low certainty) but evidence is uncertain for talc poudrage and doxycycline. Patient acceptability Pair-wise meta-analysis demonstrated that IPCs probably result in a reduced risk of requiring a repeat invasive pleural intervention (OR 0.25, 95% Cr-I 0.13 to 0.48; moderate certainty) relative to talc slurry. There is likely little difference in the risk of repeat invasive pleural intervention with talc poudrage relative to talc slurry (OR 0.96, 95% CI 0.59 to 1.56; moderate certainty). AUTHORS' CONCLUSIONS Based on the available evidence, talc poudrage and talc slurry are effective methods for achieving a pleurodesis, with lower failure rates than a number of other commonly used interventions. IPCs provide an alternative approach; whilst associated with inferior definitive pleurodesis rates, comparable control of breathlessness can probably be achieved, with a lower risk of requiring repeat invasive pleural intervention. Local availability, global experience of agents and adverse events (which may not be identified in randomised trials) and patient preference must be considered when selecting an intervention. Further research is required to delineate the roles of different treatments according to patient characteristics, such as presence of trapped lung. Greater attention to patient-centred outcomes, including breathlessness, quality of life and patient preference is essential to inform clinical decision-making. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.
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Affiliation(s)
| | - Hayley E Jones
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | | | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
| | - Nick Maskell
- University of BristolAcademic Respiratory UnitBristolUK
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Goulding N, Hickman M, Reid M, Amundsen EJ, Baz-Lomba JA, O'Brien JW, Tscharke BJ, de Voogt P, Emke E, Kuijpers W, Hall W, Jones HE. A comparison of trends in wastewater-based data and traditional epidemiological indicators of stimulant consumption in three locations. Addiction 2020; 115:462-472. [PMID: 31633843 DOI: 10.1111/add.14852] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 02/26/2019] [Revised: 06/13/2019] [Accepted: 09/27/2019] [Indexed: 12/16/2022]
Abstract
AIMS To compare long-term trends in wastewater data with other indicators of stimulant use in three locations and to test the reliability of estimates based on 1 week of sampling. DESIGN Comparison of trends in quantities ('loads') of stimulants or their metabolites in wastewater with trends in other indicators of stimulant use (e.g. treatment, police, population survey data). SETTING AND PARTICIPANTS Populations in Oslo (Norway), South-East Queensland (Australia) and Eindhoven (the Netherlands). MEASUREMENTS Wastewater data were modelled for MDMA (3,4-methylenedioxymethamphetamine), benzoylecgonine (a metabolite of cocaine), amphetamine and methamphetamine in Oslo; benzoylecgonine in Eindhoven; and methamphetamine in South-East Queensland. Choice of stimulants modelled in each region was primarily determined by availability of useable data. FINDINGS In Oslo, wastewater data, driving under the influence of drugs statistics and seizure data all suggested increasing MDMA use between 2009 and 2017. In South-East Queensland, there was an estimated 31.1% [95% confidence interval (CI) = 29.4-32.9%] annual increase in daily loads of methamphetamine in wastewater between 2009 and 2016, compared with a 14.1% (95% CI = 10.9-17.3%) annual increase in seizures. Some of the increase in wastewater can be explained by increased purity. In Eindhoven, there was no evidence of a change in cocaine consumption from wastewater, but a reduction was observed in numbers in treatment for cocaine use from 2012 to 2017. In approximately half the cases examined in Oslo, credible intervals around estimates of annual average loads from a regression model versus estimates based on a single week of sampling did not overlap. CONCLUSIONS Long-term trends in loads of stimulants in wastewater appear to be broadly consistent with trends in other indicators of stimulant use in three locations. Wastewater data should be interpreted alongside epidemiological indicators and purity data. One week of wastewater sampling may not be sufficient for valid inference about drug consumption.
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Affiliation(s)
- Neil Goulding
- Population Health Sciences, University of Bristol, Canynge Hall, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Canynge Hall, Bristol, UK
| | - Malcolm Reid
- Norwegian Institute for Water Research, Oslo, Norway
| | - Ellen J Amundsen
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Jake W O'Brien
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, QLD, Australia
| | - Ben J Tscharke
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, QLD, Australia
| | - Pim de Voogt
- KWR Water Research Institute, Nieuwegein, the Netherlands.,Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, the Netherlands
| | - Erik Emke
- KWR Water Research Institute, Nieuwegein, the Netherlands
| | - Wil Kuijpers
- Stichting Informatievoorziening Zorg (IVZ), Houten, the Netherlands
| | - Wayne Hall
- Centre for Youth Substance Abuse Research, The University of Queensland, Herston, QLD, Australia
| | - Hayley E Jones
- Population Health Sciences, University of Bristol, Canynge Hall, Bristol, UK
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Moustgaard H, Clayton GL, Jones HE, Boutron I, Jørgensen L, Laursen DRT, Olsen MF, Paludan-Müller A, Ravaud P, Savović J, Sterne JAC, Higgins JPT, Hróbjartsson A. Impact of blinding on estimated treatment effects in randomised clinical trials: meta-epidemiological study. BMJ 2020; 368:l6802. [PMID: 31964641 PMCID: PMC7190062 DOI: 10.1136/bmj.l6802] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To study the impact of blinding on estimated treatment effects, and their variation between trials; differentiating between blinding of patients, healthcare providers, and observers; detection bias and performance bias; and types of outcome (the MetaBLIND study). DESIGN Meta-epidemiological study. DATA SOURCE Cochrane Database of Systematic Reviews (2013-14). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Meta-analyses with both blinded and non-blinded trials on any topic. REVIEW METHODS Blinding status was retrieved from trial publications and authors, and results retrieved automatically from the Cochrane Database of Systematic Reviews. Bayesian hierarchical models estimated the average ratio of odds ratios (ROR), and estimated the increases in heterogeneity between trials, for non-blinded trials (or of unclear status) versus blinded trials. Secondary analyses adjusted for adequacy of concealment of allocation, attrition, and trial size, and explored the association between outcome subjectivity (high, moderate, low) and average bias. An ROR lower than 1 indicated exaggerated effect estimates in trials without blinding. RESULTS The study included 142 meta-analyses (1153 trials). The ROR for lack of blinding of patients was 0.91 (95% credible interval 0.61 to 1.34) in 18 meta-analyses with patient reported outcomes, and 0.98 (0.69 to 1.39) in 14 meta-analyses with outcomes reported by blinded observers. The ROR for lack of blinding of healthcare providers was 1.01 (0.84 to 1.19) in 29 meta-analyses with healthcare provider decision outcomes (eg, readmissions), and 0.97 (0.64 to 1.45) in 13 meta-analyses with outcomes reported by blinded patients or observers. The ROR for lack of blinding of observers was 1.01 (0.86 to 1.18) in 46 meta-analyses with subjective observer reported outcomes, with no clear impact of degree of subjectivity. Information was insufficient to determine whether lack of blinding was associated with increased heterogeneity between trials. The ROR for trials not reported as double blind versus those that were double blind was 1.02 (0.90 to 1.13) in 74 meta-analyses. CONCLUSION No evidence was found for an average difference in estimated treatment effect between trials with and without blinded patients, healthcare providers, or outcome assessors. These results could reflect that blinding is less important than often believed or meta-epidemiological study limitations, such as residual confounding or imprecision. At this stage, replication of this study is suggested and blinding should remain a methodological safeguard in trials.
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Affiliation(s)
- Helene Moustgaard
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, DK-5000 Odense C, Denmark
- Nordic Cochrane Centre, Copenhagen, Denmark
| | - Gemma L Clayton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - David R T Laursen
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, DK-5000 Odense C, Denmark
- Nordic Cochrane Centre, Copenhagen, Denmark
| | | | | | | | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, DK-5000 Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Moustgaard H, Jones HE, Savović J, Clayton GL, Sterne JAC, Higgins JPT, Hróbjartsson A. Ten questions to consider when interpreting results of a meta‐epidemiological study—the MetaBLIND study as a case. Res Synth Methods 2020; 11:260-274. [PMID: 31851427 DOI: 10.1002/jrsm.1392] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/22/2019] [Accepted: 12/13/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Helene Moustgaard
- Centre for Evidence‐Based Medicine Odense (CEBMO)Odense University Hospital Odense C Denmark
- Department of Clinical ResearchUniversity of Southern Denmark Odense M Denmark
- Open patient Data Explorative Network (OPEN)Odense University Hospital Odense C Denmark
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical SchoolUniversity of Bristol Bristol UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical SchoolUniversity of Bristol Bristol UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West)University Hospitals Bristol NHS Foundation Trust Bristol UK
| | - Gemma L Clayton
- Population Health Sciences, Bristol Medical SchoolUniversity of Bristol Bristol UK
| | - Jonathan AC Sterne
- Population Health Sciences, Bristol Medical SchoolUniversity of Bristol Bristol UK
| | - Julian PT Higgins
- Population Health Sciences, Bristol Medical SchoolUniversity of Bristol Bristol UK
| | - Asbjørn Hróbjartsson
- Centre for Evidence‐Based Medicine Odense (CEBMO)Odense University Hospital Odense C Denmark
- Department of Clinical ResearchUniversity of Southern Denmark Odense M Denmark
- Open patient Data Explorative Network (OPEN)Odense University Hospital Odense C Denmark
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Padmanathan P, Hall K, Moran P, Jones HE, Gunnell D, Carlisle V, Lingford-Hughes A, Hickman M. Prevention of suicide and reduction of self-harm among people with substance use disorder: A systematic review and meta-analysis of randomised controlled trials. Compr Psychiatry 2020; 96:152135. [PMID: 31810026 DOI: 10.1016/j.comppsych.2019.152135] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 07/17/2019] [Revised: 09/19/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND People with substance use disorder (SUD) are at significantly greater risk of suicide compared with the general population. In recent years the number of suicides resulting from drug poisoning in England and Wales has increased. We sought to identify and evaluate the effect of interventions to prevent suicide or reduce self-harm among people with SUD. METHODS We conducted a systematic review of randomised controlled trials (RCTs) of interventions for people with SUD that included suicide or self-harm-related primary outcomes. We searched Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, PubMed, Embase and Web of Science from inception until 13th January 2019. Studies were assessed for bias using the Cochrane Risk of Bias 2 tool. A random effects meta-analysis of standardised mean differences (SMD) was conducted. RESULTS We identified six RCTs from four countries (Australia, Iran, the United States of America and the United Kingdom) comprising 468 participants in total. All but one study investigated psychosocial interventions. On average across studies there was weak evidence of a small positive effect of interventions on suicide or self-harm outcomes (d=-0.20, 95% CI=-0.39-0.00). LIMITATIONS Studies were heterogeneous in terms of population, intervention, controls and outcome. There were some concerns regarding bias for all trials. All trials were liable to type II error. CONCLUSIONS Evidence is currently lacking regarding the effectiveness of interventions to prevent suicide and reduce self-harm amongst people with SUD.
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Affiliation(s)
- Prianka Padmanathan
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom.
| | - Katherine Hall
- Avon & Wiltshire Mental Health Partnership NHS Trust, United Kingdom
| | - Paul Moran
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom; National Institute for Health Research, Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - David Gunnell
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom; National Institute for Health Research, Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Victoria Carlisle
- School of Psychological Science, University of Bristol, United Kingdom
| | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom; National Institute for Health Research, Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Jones HE, Gatsonsis CA, Trikalinos TA, Welton NJ, Ades AE. Quantifying how diagnostic test accuracy depends on threshold in a meta-analysis. Stat Med 2019; 38:4789-4803. [PMID: 31571244 PMCID: PMC6856843 DOI: 10.1002/sim.8301] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 12/31/2022]
Abstract
Tests for disease often produce a continuous measure, such as the concentration of some biomarker in a blood sample. In clinical practice, a threshold C is selected such that results, say, greater than C are declared positive and those less than C negative. Measures of test accuracy such as sensitivity and specificity depend crucially on C, and the optimal value of this threshold is usually a key question for clinical practice. Standard methods for meta‐analysis of test accuracy (i) do not provide summary estimates of accuracy at each threshold, precluding selection of the optimal threshold, and furthermore, (ii) do not make use of all available data. We describe a multinomial meta‐analysis model that can take any number of pairs of sensitivity and specificity from each study and explicitly quantifies how accuracy depends on C. Our model assumes that some prespecified or Box‐Cox transformation of test results in the diseased and disease‐free populations has a logistic distribution. The Box‐Cox transformation parameter can be estimated from the data, allowing for a flexible range of underlying distributions. We parameterise in terms of the means and scale parameters of the two logistic distributions. In addition to credible intervals for the pooled sensitivity and specificity across all thresholds, we produce prediction intervals, allowing for between‐study heterogeneity in all parameters. We demonstrate the model using two case study meta‐analyses, examining the accuracy of tests for acute heart failure and preeclampsia. We show how the model can be extended to explore reasons for heterogeneity using study‐level covariates.
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Affiliation(s)
- Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Constantine A Gatsonsis
- Department of Biostatistics, Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island.,Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Thomas A Trikalinos
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - A E Ades
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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McAleenan A, Jones HE, Kernohan A, Faulkner CL, Palmer A, Dawson S, Wragg C, Jefferies S, Brandner S, Vale L, Higgins JPT, Kurian KM. Diagnostic test accuracy and cost-effectiveness of tests for codeletion of chromosomal arms 1p and 19q in people with glioma. Hippokratia 2019. [DOI: 10.1002/14651858.cd013387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alexandra McAleenan
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Hayley E Jones
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Ashleigh Kernohan
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Claire L Faulkner
- Southmead Hospital; Bristol Genetics Laboratory, Pathology Sciences; North Bristol NHS Trust Bristol UK BS10 5NB
| | - Abigail Palmer
- Southmead Hospital; Bristol Genetics Laboratory, Pathology Sciences; North Bristol NHS Trust Bristol UK BS10 5NB
| | - Sarah Dawson
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Christopher Wragg
- Southmead Hospital; Bristol Genetics Laboratory, Pathology Sciences; North Bristol NHS Trust Bristol UK BS10 5NB
| | - Sarah Jefferies
- Addenbrooke's Hospital; Department of Oncology; Hills Road Cambridge UK CB2 0QQ
| | - Sebastian Brandner
- The National Hospital for Neurology and Neurosurgery; Division of Neuropathology and Department of Neurodegeneration; University College Hospital NHS Foundation Trust and UCL Institute of Neurology Queen Square London UK WC1N 3BG
| | - Luke Vale
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Julian P T Higgins
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Kathreena M Kurian
- University of Bristol; Bristol Medical School: Brain Tumour Research Centre, Public Health Sciences; Oakfield House, Oakfield Grove Bristol UK BS8 2BN
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Jones HE, Ades AE, Sutton AJ, Welton NJ. Use of a random effects meta-analysis in the design and analysis of a new clinical trial. Stat Med 2018; 37:4665-4679. [PMID: 30187505 PMCID: PMC6484819 DOI: 10.1002/sim.7948] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 06/20/2016] [Revised: 06/29/2018] [Accepted: 07/28/2018] [Indexed: 01/08/2023]
Abstract
In designing a randomized controlled trial, it has been argued that trialists should consider existing evidence about the likely intervention effect. One approach is to form a prior distribution for the intervention effect based on a meta‐analysis of previous studies and then power the trial on its ability to affect the posterior distribution in a Bayesian analysis. Alternatively, methods have been proposed to calculate the power of the trial to influence the “pooled” estimate in an updated meta‐analysis. These two approaches can give very different results if the existing evidence is heterogeneous, summarised using a random effects meta‐analysis. We argue that the random effects mean will rarely represent the trialist's target parameter, and so, it will rarely be appropriate to power a trial based on its impact upon the random effects mean. Furthermore, the random effects mean will not generally provide an appropriate prior distribution. More appropriate alternatives include the predictive distribution and shrinkage estimate for the most similar study. Consideration of the impact of the trial on the entire random effects distribution might sometimes be appropriate. We describe how beliefs about likely sources of heterogeneity have implications for how the previous evidence should be used and can have a profound impact on the expected power of the new trial. We conclude that the likely causes of heterogeneity among existing studies need careful consideration. In the absence of explanations for heterogeneity, we suggest using the predictive distribution from the meta‐analysis as the basis for a prior distribution for the intervention effect.
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Affiliation(s)
- Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - A E Ades
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Jones HE, Goulding N, Hickman M. Commentary on Lai et al. (2018): Potential and limitations of wastewater-based epidemiology in monitoring substance use. Addiction 2018; 113:1137-1138. [PMID: 29732695 DOI: 10.1111/add.14207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Neil Goulding
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Savović J, Turner RM, Mawdsley D, Jones HE, Beynon R, Higgins JPT, Sterne JAC. Association Between Risk-of-Bias Assessments and Results of Randomized Trials in Cochrane Reviews: The ROBES Meta-Epidemiologic Study. Am J Epidemiol 2018; 187:1113-1122. [PMID: 29126260 PMCID: PMC5928453 DOI: 10.1093/aje/kwx344] [Citation(s) in RCA: 256] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 10/17/2017] [Indexed: 11/25/2022] Open
Abstract
Flaws in the design of randomized trials may bias intervention effect estimates and increase between-trial heterogeneity. Empirical evidence suggests that these problems are greatest for subjectively assessed outcomes. For the Risk of Bias in Evidence Synthesis (ROBES) Study, we extracted risk-of-bias judgements (for sequence generation, allocation concealment, blinding, and incomplete data) from a large collection of meta-analyses published in the Cochrane Library (issue 4; April 2011). We categorized outcome measures as mortality, other objective outcome, or subjective outcome, and we estimated associations of bias judgements with intervention effect estimates using Bayesian hierarchical models. Among 2,443 randomized trials in 228 meta-analyses, intervention effect estimates were, on average, exaggerated in trials with high or unclear (versus low) risk-of-bias judgements for sequence generation (ratio of odds ratios (ROR) = 0.91, 95% credible interval (CrI): 0.86, 0.98), allocation concealment (ROR = 0.92, 95% CrI: 0.86, 0.98), and blinding (ROR = 0.87, 95% CrI: 0.80, 0.93). In contrast to previous work, we did not observe consistently different bias for subjective outcomes compared with mortality. However, we found an increase in between-trial heterogeneity associated with lack of blinding in meta-analyses with subjective outcomes. Inconsistency in criteria for risk-of-bias judgements applied by individual reviewers is a likely limitation of routinely collected bias assessments. Inadequate randomization and lack of blinding may lead to exaggeration of intervention effect estimates in randomized trials.
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Affiliation(s)
- Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research
| | - Rebecca M Turner
- Medical Research Council
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - David Mawdsley
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Rebecca Beynon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research
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Rhodes KM, Turner RM, Savović J, Jones HE, Mawdsley D, Higgins JPT. Between-trial heterogeneity in meta-analyses may be partially explained by reported design characteristics. J Clin Epidemiol 2018; 95:45-54. [PMID: 29217451 PMCID: PMC5828111 DOI: 10.1016/j.jclinepi.2017.11.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 11/10/2017] [Accepted: 11/28/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We investigated the associations between risk of bias judgments from Cochrane reviews for sequence generation, allocation concealment and blinding, and between-trial heterogeneity. STUDY DESIGN AND SETTING Bayesian hierarchical models were fitted to binary data from 117 meta-analyses, to estimate the ratio λ by which heterogeneity changes for trials at high/unclear risk of bias compared with trials at low risk of bias. We estimated the proportion of between-trial heterogeneity in each meta-analysis that could be explained by the bias associated with specific design characteristics. RESULTS Univariable analyses showed that heterogeneity variances were, on average, increased among trials at high/unclear risk of bias for sequence generation (λˆ 1.14, 95% interval: 0.57-2.30) and blinding (λˆ 1.74, 95% interval: 0.85-3.47). Trials at high/unclear risk of bias for allocation concealment were on average less heterogeneous (λˆ 0.75, 95% interval: 0.35-1.61). Multivariable analyses showed that a median of 37% (95% interval: 0-71%) heterogeneity variance could be explained by trials at high/unclear risk of bias for sequence generation, allocation concealment, and/or blinding. All 95% intervals for changes in heterogeneity were wide and included the null of no difference. CONCLUSION Our interpretation of the results is limited by imprecise estimates. There is some indication that between-trial heterogeneity could be partially explained by reported design characteristics, and hence adjustment for bias could potentially improve accuracy of meta-analysis results.
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Affiliation(s)
- Kirsty M Rhodes
- MRC Biostatistics Unit, School of Clinical Medicine, Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Rebecca M Turner
- MRC Biostatistics Unit, School of Clinical Medicine, Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK; MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, 2nd Floor, London WC1V 6LJ, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK; NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Whitefriars, Lewins Mead, Bristol BS1 2NT, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - David Mawdsley
- University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
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Rhodes KM, Mawdsley D, Turner RM, Jones HE, Savović J, Higgins JPT. Label-invariant models for the analysis of meta-epidemiological data. Stat Med 2017; 37:60-70. [PMID: 28929507 PMCID: PMC5724693 DOI: 10.1002/sim.7491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 07/27/2017] [Accepted: 08/20/2017] [Indexed: 11/06/2022]
Abstract
Rich meta‐epidemiological data sets have been collected to explore associations between intervention effect estimates and study‐level characteristics. Welton et al proposed models for the analysis of meta‐epidemiological data, but these models are restrictive because they force heterogeneity among studies with a particular characteristic to be at least as large as that among studies without the characteristic. In this paper we present alternative models that are invariant to the labels defining the 2 categories of studies. To exemplify the methods, we use a collection of meta‐analyses in which the Cochrane Risk of Bias tool has been implemented. We first investigate the influence of small trial sample sizes (less than 100 participants), before investigating the influence of multiple methodological flaws (inadequate or unclear sequence generation, allocation concealment, and blinding). We fit both the Welton et al model and our proposed label‐invariant model and compare the results. Estimates of mean bias associated with the trial characteristics and of between‐trial variances are not very sensitive to the choice of model. Results from fitting a univariable model show that heterogeneity variance is, on average, 88% greater among trials with less than 100 participants. On the basis of a multivariable model, heterogeneity variance is, on average, 25% greater among trials with inadequate/unclear sequence generation, 51% greater among trials with inadequate/unclear blinding, and 23% lower among trials with inadequate/unclear allocation concealment, although the 95% intervals for these ratios are very wide. Our proposed label‐invariant models for meta‐epidemiological data analysis facilitate investigations of between‐study heterogeneity attributable to certain study characteristics.
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Affiliation(s)
- K M Rhodes
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - D Mawdsley
- University of Manchester, Manchester, UK
| | - R M Turner
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.,MRC Clinical Trials Unit, University College London, UK
| | - H E Jones
- School of Social and Community Medicine, University of Bristol, UK
| | - J Savović
- School of Social and Community Medicine, University of Bristol, UK.,NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - J P T Higgins
- School of Social and Community Medicine, University of Bristol, UK
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