RATIONALE:Obstructive sleep apnea (OSA) and hypertension are common comorbidities and are associated with poor prognosis. Blood pressure (BP) trajectories using home BP monitoring after initiation of continuous positive airway pressure (CPAP) therapy for OSA are poorly documented. OBJECTIVES:To describe BP trajectories in the first 6 months after CPAP therapy initiation based on repeated longitudinal measurements of home BP, to evaluate the impact of CPAP on morning and evening home BP, and to identify predictors of home BP evolution during CPAP. METHODS:This prospective cohort study enrolled patients with OSA. Home BP monitoring was used to assess morning and evening home BP values over a 7-day period at baseline and over the first 6 months after starting CPAP therapy. RESULTS:A total of 98 patients were enrolled, and 36,600 home BP measurements were available for analysis. Morning and evening systolic/diastolic home BP decreased significantly during the first 6 months of CPAP therapy (P < 0.05 vs. baseline). Morning home BP was significantly higher than evening home BP throughout the study (P < 0.01). After adjustment for OSA severity at baseline and CPAP adherence, factors associated with limited home BP response to CPAP were older age, weight gain during CPAP therapy, current smoking, and previous hypertension. CONCLUSIONS:CPAP improved home BP trajectories during the first 6 months, but the response was heterogeneous and less marked for morning BP values. Based on the predictors of BP response during CPAP therapy, weight control appears key to the effective management of patients with OSA and hypertension.Clinical trial registered with www. CLINICALTRIALS:gov (NCT04963192 and NCT04054180).
ABSTRACT Although clinical trials showed outcomes improvement in MCL, their applicability to real‐world practice remains limited. Using the prospective REALYSA registry (NCT03869619), we evaluated contemporary management, highlighting evolving practices and differences by age. Among 295 patients, 63% were ≥ 65 years, 48% had a high‐risk MIPI score with Ki‐67 ≥ 30% in 53% and aggressive morphology in 11%. Younger patients received high‐dose cytarabine (93%) and ASCT (78%). Older patients were treated with bendamustine‐rituximab (28%), R‐CHOP (18%), and low‐dose cytarabine (20%). Two‐year event‐free (EFS‐2y) and overall (OS‐2y) survivals were 80% and 89% in < 65y; 60% and 77% in ≥ 65y. Among 238 patients responders after induction, rituximab maintenance (RM) use was frequent but lower in older patients (88% vs. 76%). In time‐dependent Cox models adjusted for age (< 65 vs. ≥ 65) and MIPI, RM was associated with a lower hazard of EFS events (HR 0.48; 95% CI: 0.25–0.92), although residual confounding related to treatment selection may remain. In the second‐line setting ( n = 72), most patients were POD24 (89%) and 56% received ibrutinib, yet outcomes remained poor (CR 24%, ORR 35%, median EFS and OS of 6.3 and 25.6 months, respectively). These findings underscore the need for improved strategies for older and high‐risk patients. Retrospective landmark analyses suggest a potential association between RM and improved EFS but are limited by baseline differences between groups.
Background:Closed-loop insulin delivery is the new standard of care for patients with type 1 diabetes (T1D). However, in France, its implementation remains predominantly hospital based. Expanding access to this treatment through alternative care models looks essential. Objective:This study (cost-effectiveness analysis) compares 2 care models for people with T1D implementing a closed-loop system in France: outpatient care in the Inter-Regional Center for Automated Insulin in Diabetes (CIRDIA) and inpatient care. Methods:We conducted a cost-effectiveness analysis using retrospective observational data from individuals with T1D aged 16 years and older from the implementation of the closed loop to a 12-month follow-up either in the CIRDIA (CIRDIA group) or in a hospital center setting (hospital center [HC] group). The cost analyses were based on patient records and public databases: the French Medical Information Systems Program and the French General Nomenclature of Professional Acts. Closed-loop efficacy was assessed using a time in range (TIR) of 70 to 180 mg/dL, and closed-loop safety was assessed using the glycemia risk index (GRI), a single indicator that represents the risk of hypoglycemia or hyperglycemia and ranges from 0 (minimal risk) to 100 (maximal risk). Results:A total of 201 patients were included: 128 in the CIRDIA group and 73 in the HC group. The mean (SD) age was 43 (14) years and 46 (15) years, respectively. Mean (SD) baseline TIR was 52.9% (16%) in the CIRDIA group versus 65.9% (15.1%) in the HC group (P<.001), whereas mean (SD) baseline GRI was 56.4 (21) in the CIRDIA group versus 37.8 (19.8) in the HC group (P<.001). After 12 months, both groups achieved similar efficacy and safety outcomes with a mean (SD) TIR at 72.7% (11.6%) in the CIRDIA group versus 71.9% (10.5%) in the HC group, and a mean GRI at 30.1 (14.1) versus 30.3 (13), respectively. There were no significant between-group differences (P=.60 for TIR; P=.91 for GRI). However, the CIRDIA was associated with significantly lower management costs with a mean cost of €8373.12 (SD €427.30; €1=US $1.10 at the time of the study) per patient in the CIRDIA group versus €8814.32 (SD €192) per patient in the HC group (P<.001). The estimated saving was €626 per percentage point of increase in TIR and €2011 per point of reduction in GRI, indicating that the HC closed-loop initiation was dominated by the CIRDIA. The CIRDIA was less costly than HC in 8600 (86%) out of 10,000 simulations in a probabilistic sensitivity analysis. Conclusions:These findings suggest the potential of the CIRDIA to represent a viable alternative organizational model for closed-loop initiation in France, achieving comparable effectiveness at lower cost in our population. Further research with longer follow-up is warranted. From a policy perspective, the resources saved could be at least partly reallocated to support out-of-hospital closed-loop initiation centers.
