Multiple Risk Factor Control in Individuals with Type 2 Diabetes and Microalbuminuria

The overall aim of this PhD was to evaluate the long-term clinical, and cost-effectiveness of multiple risk factor control defined as intensive control of blood glucose, blood pressure and lipid levels, either singularly or in combination as a multifactorial intervention in individuals with type 2 diabetes and microalbuminuria, when compared to standard care.The results from systematic review and meta-analysis suggested that interventions for risk factors control favour the trends towards a reduction in the risk of myocardial infarction (MI) [risk ratio (RR) 0.50; 95% confidence interval (CI) 0.20,1.22; P=0.127], stroke (RR 0.44; 95% CI 0.10,1.91; P=0.275), CV-mortality (RR 0.95; 95% CI 0.48,1.86; P=0.874) or all-cause mortality (RR 0.80; 95% CI 0.51,1.25; P=0.324). Whereas the cohort analysis of real-world data from the United Kingdom (UK) primary care provided evidence that being at blood glucose, blood pressure, and cholesterol targets was associated with an overall 47%, 25%, 42%, 55% and 42% reduction in the risk of MI, stroke, renal disease, CV-mortality, and all-cause-mortality, respectively. The findings of the economic evaluation indicated that achieving multiple risk factor control in individuals with type 2 diabetes were not cost-effective [incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained was £39,750, with the probability of being cost-effective was 0.3375] in a UK setting; however, in the subgroup of individuals with type 2 diabetes and microalbuminuria, achieving multiple risk factor control were potentially cost-effective [ICER per QALY gained was £1,366, with the probability of being cost-effective was 0.5100].This thesis has assessed the long-term clinical, and cost-effectiveness of multiple risk factor control, through evidence synthesis methodologies, retrospective cohort analysis, and economic evaluation in people with type 2 diabetes and the subgroup of individuals with type 2 diabetes and microalbuminuria. However, uncertainty still surrounds the cost-effectiveness of multiple risk factor control, and further research is required.</div

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Additional file 1 of Optimal control analysis of Ebola disease with control strategies of quarantine and vaccination

Please see Additional file 1 for translations of the abstract into the five official working languages of the United Nations. (PDF 378 kb

L'Auto-vélo : automobilisme, cyclisme, athlétisme, yachting, aérostation, escrime, hippisme / dir. Henri Desgranges

21 février 19031903/02/21 (A4,N860)

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Additional file 6: Table S6. This table presents ligand binding sites prediction of hypothetical proteins of human adenovirus

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Cost-effectiveness of intensive interventions compared to standard care in individuals with type 2 diabetes: A systematic review and critical appraisal of decision-analytic models.

AIMS:The objective of this systematic review is to identify and assess the quality of published decision-analytic models evaluating the long-term cost-effectiveness of target-driven intensive interventions for single and multifactorial risk factor control compared to standard care in people with type 2 diabetes. METHODS:We searched the electronic databases MEDLINE, the National Health Service Economic Evaluation Database, Web of Science and the Cochrane Library from inception to October 31, 2019. Articles were eligible for inclusion if the studies had used a decision-analytic model evaluating both the long-term costs and benefits associated with intensive interventions for risk factor control compared to standard care in people with type 2 diabetes. Data were extracted using a standardised form, while quality was assessed using the decision-analytic model-specific Philips-criteria. RESULTS:Overall, nine articles (11 models) were identified, four models evaluated intensive glycaemic control, three evaluated intensive blood pressure control, two evaluated intensive lipid control, and two evaluated intensive multifactorial interventions. Six reported using discrete-time simulations modelling approach, whereas five reported using a Markov modelling framework. The majority, seven studies, reported that the intensive interventions were dominant or cost-effective, given the assumptions and analytical perspective taken. The methodological and reporting quality of the studies was generally weak, with only four studies fulfilling more than 50% of their applicable Philips-criteria. CONCLUSIONS:This is the first systematic review of decision-analytic models of target-driven intensive interventions for single and multifactorial risk factor control in individuals with type 2 diabetes. Identified shortcomings are lack of transparency in data identification and evidence synthesis as well as for the selection of the modelling approaches. Future models should aim to include greater evaluation of the quality of the data sources used and the assessment of uncertainty in the model

Association and relative importance of multiple risk factor control on cardiovascular disease, end-stage renal disease and mortality in people with type 2 diabetes: A population-based retrospective cohort study

Aims: To evaluate the risk of cardiovascular disease (CVD), end-stage renal disease (ESRD), and mortality, when implementing a multifactorial optimal control approach in primary care in the United Kingdom (UK), in individuals with newly diagnosed type 2 diabetes. Materials and methods: A retrospective cohort of 53 942 patients were stratified into 1 of the 8 groups according to whether glycated haemoglobin (HbA1c), blood pressure (BP) and total cholesterol (TC) target values were achieved or not from baseline to the date of last follow-up. Those with single or combinations of risk factor control targets achieved, were compared to those who achieved no targets in any of the risk factor. Hazard ratios from the Cox proportional hazards models were estimated against patients who achieved no targets. Results: Of 53 942 patients with newly diagnosed type 2 diabetes, 28%, 55%, and 68% were at target levels for HbA1c <48 mmol/mol (<6.5%), BP < 140/85 mm Hg, and TC < 5 mmol/L respectively, 36%, 40%, and 12% were at target levels for any one, two, or all three risk factors respectively. Being at HbA1c, BP, and TC targets was associated with an overall 47%, 25%, 42%, 55% and 42% reduction in the risk of ischemic heart disease, cerebrovascular disease, ESRD, cardiovascular-mortality, and all-cause-mortality respectively. Among all subgroups, the risk reduction of study outcome events was greater in the subgroups of patients with microalbuminuria, males, smokers, and patients with BMI ≥ 30 kg/m2. Conclusions: Optimal levels of HbA1c, BP, and TC occurring together in patients with newly diagnosed type 2 diabetes are uncommon. Achieving multiple risk factor control targets could substantially reduce the risk of CVD, ESRD and mortality