Non-interventional study Dotaz Zobrazit nápovědu
INTRODUCTION: In recognition of the value of long-term real-world data, a postauthorization safety study of the inhaled corticosteroid (ICS) fluticasone propionate and long-acting β2-agonist (LABA) formoterol fumarate (fluticasone/formoterol; Flutiform®) was conducted. METHODS: This was a 12-month observational study of outpatients with asthma aged ⩾ 12 years in eight European countries. Patients were prescribed fluticasone/formoterol according to the licensed indication, and independently of their subsequent enrolment in the study. They were then treated according to local standard practice. The study objectives were to evaluate the safety and effectiveness of fluticasone/formoterol under real-world conditions. RESULTS: The safety population for this study comprised 2539 patients (mean age 47.7 years; 94.3% aged ⩾ 18 years; 63.4% female). Most patients (1538/2539, 60.6%) had switched to fluticasone/formoterol from another ICS/LABA, primarily due to lack of efficacy (1150/2539, 45.3%). Three quarters (77.4%) of patients were treated for 12 months, and 80.6% continued fluticasone/formoterol treatment after the study. Adverse events (AEs) occurred in 60.0% patients, and 10.2% had AEs considered possibly related to fluticasone/formoterol [most commonly asthma exacerbation (2.0% patients), dysphonia (1.8%) and cough (1.1%)]. Thirty-six severe AEs, but no serious AEs, were considered possibly related to fluticasone/formoterol. The proportion of patients with controlled asthma (based on Asthma Control Test score ⩾ 20) increased from 29.4% at baseline to 67.4% at study end (last observation carried forward). The proportion of patients experiencing at least one severe exacerbation decreased from 35.8% in the year prior to enrolment to 9.8% during the study. Improvements from baseline to study end were also observed in Asthma Quality of Life scores and physician/patient reports of satisfaction with treatment. CONCLUSION: In this real-world postauthorization safety study, fluticasone/formoterol demonstrated a safety profile consistent with that seen in controlled clinical trials, with effectiveness in improving asthma control.
- Klíčová slova
- asthma, fluticasone propionate, formoterol fumarate, non-interventional study, real world, safety,
- MeSH
- antiastmatika aplikace a dávkování MeSH
- bronchiální astma farmakoterapie patofyziologie MeSH
- dítě MeSH
- dospělí MeSH
- fixní kombinace léků MeSH
- flutikason aplikace a dávkování škodlivé účinky MeSH
- formoterol fumarát aplikace a dávkování škodlivé účinky MeSH
- kvalita života * MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- spokojenost pacientů MeSH
- výsledek terapie MeSH
- Check Tag
- dítě MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
- Názvy látek
- antiastmatika MeSH
- fixní kombinace léků MeSH
- fluticasone-formoterol MeSH Prohlížeč
- flutikason MeSH
- formoterol fumarát MeSH
BACKGROUND: The Clinical COPD Questionnaire (CCQ) is a simple patient-reported tool to measure clinical control of chronic obstructive pulmonary disease (COPD). OBJECTIVE: This open-label, single-arm, non-interventional study (NCT03663569) investigated changes in CCQ score during treatment with tiotropium/olodaterol in clinical practice. METHODS: Data were included from consenting COPD patients, enrolled in Bulgaria, Czech Republic, Hungary, Israel, Lithuania, Poland, Romania, Russia, Slovenia, Switzerland and Ukraine, who were receiving a new prescription for tiotropium/olodaterol according to the treating physician in a real-world environment. The primary endpoint was the occurrence of therapeutic success, defined as a 0.4-point decrease in CCQ score after treatment with tiotropium/olodaterol for approximately 6 weeks. RESULTS: Overall, 4819 patients were treated; baseline and Week 6 CCQ scores were available for 4700 patients, mostly classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) B (51.6%) or D (42.7%). After 6 weeks' treatment, 81.4% (95% confidence interval [95% CI] 80.24-82.49) of patients achieved therapeutic success; mean improvement in overall CCQ score was 1.02 points (95% CI 1.00-1.05). Improved CCQ score was seen in 92.2% of patients (95% CI 91.43-92.98), 2.5% had no change and 5.3% showed a worsening. When stratified by prior treatment, the greatest benefit was seen in treatment-naïve patients, with 85.7% achieving therapeutic success, compared with 79.5% of those pretreated with long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) and 74.2% of those pretreated with LABA or long-acting muscarinic antagonist (LAMA) monotherapy. Overall, rescue medication decreased by 1.25 puffs/day (95% CI 1.19-1.31) versus baseline. In total, 29 patients (0.6%) reported drug-related adverse events and 7 patients reported serious adverse events (0.15%). CONCLUSION: In 4700 COPD patients, 6 weeks' treatment with tiotropium/olodaterol, as initial treatment or follow-up to LAMA or LABA monotherapy or LABA/ICS, improved CCQ and decreased rescue medication use. The adverse event profile was consistent with the known safety profile of tiotropium/olodaterol.
- Klíčová slova
- CCQ *, COPD *, Clinical COPD Questionnaire *, non-interventional study *, olodaterol *, tiotropium *,
- MeSH
- agonisté beta-2-adrenergních receptorů škodlivé účinky MeSH
- antagonisté muskarinových receptorů škodlivé účinky MeSH
- aplikace inhalační MeSH
- benzoxaziny terapeutické užití MeSH
- bronchodilatancia škodlivé účinky MeSH
- chronická obstrukční plicní nemoc * diagnóza farmakoterapie MeSH
- fixní kombinace léků MeSH
- lidé MeSH
- průzkumy a dotazníky MeSH
- tiotropium bromid škodlivé účinky MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
- klinické zkoušky MeSH
- Geografické názvy
- Bulharsko MeSH
- Česká republika MeSH
- Izrael MeSH
- Maďarsko MeSH
- Polsko MeSH
- Rumunsko MeSH
- Rusko MeSH
- Švýcarsko MeSH
- Názvy látek
- agonisté beta-2-adrenergních receptorů MeSH
- antagonisté muskarinových receptorů MeSH
- benzoxaziny MeSH
- bronchodilatancia MeSH
- fixní kombinace léků MeSH
- olodaterol MeSH Prohlížeč
- tiotropium bromid MeSH
Adapted automated peritoneal dialysis (aAPD), comprising a sequence of dwells with different durations and fill volumes, has been shown to enhance both ultrafiltration and solute clearance compared to standard peritoneal dialysis with constant time and volume dwells. The aim of this non-interventional study was to describe the different prescription patterns used in aAPD in clinical practice and to observe outcomes characterizing volume status, dialysis efficiency, and residual renal function over 1 year. Prevalent and incident, adult aAPD patients were recruited during routine clinic visits, and aAPD prescription, volume status, residual renal function and laboratory data were documented at baseline and every quarter thereafter for 1 year. Treatments were prescribed according to the nephrologist's medical judgement in accordance with each center's clinical routine. Of 180 recruited patients, 160 were analyzed. 27 different aAPD prescription patterns were identified. 79 patients (49.4%) received 2 small, short dwells followed by 3 long, large dwells. During follow-up, volume status changed only marginally, with visit mean values ranging between 1.59 (95% confidence interval: 1.19; 1.99) and 1.97 (1.33; 2.61) L. Urine output and creatinine clearance decreased significantly, accompanied by reductions in ultrafiltration and Kt/V. 25 patients (15.6%) received a renal transplant and 15 (9.4%) were changed to hemodialysis. Options for individualization offered by aAPD are actually used in practice for optimized treatment. Changes observed in renal function and dialysis efficiency measures reflect the natural course of chronic kidney disease. No safety events were observed during the study period.
- MeSH
- chronické selhání ledvin terapie moč MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- následné studie MeSH
- peritoneální dialýza * MeSH
- prospektivní studie MeSH
- senioři MeSH
- vyšetření funkce ledvin MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
OBJECTIVE: Observational studies can provide evidence about patient outcomes in routine clinical practice. This prospective, non-interventional study (BELIEVE) is the largest real-world European study to date to assess quality-of-life, treatment satisfaction, resource utilization, and persistence in patients with overactive bladder (OAB) who were prescribed mirabegron as part of routine clinical practice. METHODS: The primary objective was to evaluate change from baseline in quality-of-life based on overactive bladder questionnaire (OAB-q) sub-scales. Secondary objectives included evaluation of treatment persistence, patient satisfaction, healthcare resource utilization and adverse events (AEs). Follow-up was for 12 months with visit windows at 2-4 and 10-12 months. Median change from baseline in total OAB-q and its sub-scales (Health-related quality-of-life [HRQoL] and symptom bother scale) were assessed. RESULTS: Overall, 862 patients were enrolled from eight European countries. In the Full Analysis Set (FAS), 73.7% were female, mean age was 61.2 years; 47.7% ≥65 years. At baseline, 41.3% had switched from other OAB treatments, 42.2% were treatment naïve, 10.1% were lapsed, and 6.4% were on combination treatment. Symptom bother and HRQoL total scores improved from baseline to 2-4 and 10-12 months. There was a notable improvement in dry rate, increasing from 34.9% at baseline to 43.7% at 10-12 months in the FAS, and a reduction in pad use. Persistence was high, with 53.8% of FAS patients remaining on mirabegron at 10-12 months. Overall, no unexpected safety issues were observed and AEs were consistent with the known safety profile of mirabegron. CONCLUSION: Patients receiving mirabegron in a real-world setting reported meaningful improvements in QoL and health status, with a persistence rate of 53.8% at 12 months for the FAS. No unexpected safety issues were observed, and AEs were consistent with the known safety profile of mirabegron.
- Klíčová slova
- Mirabegron, overactive bladder, persistence,
- MeSH
- acetanilidy terapeutické užití MeSH
- hyperaktivní močový měchýř * farmakoterapie epidemiologie psychologie MeSH
- kvalita života * MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- průzkumy a dotazníky MeSH
- senioři MeSH
- spokojenost pacientů statistika a číselné údaje MeSH
- thiazoly terapeutické užití MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- Názvy látek
- acetanilidy MeSH
- mirabegron MeSH Prohlížeč
- thiazoly MeSH
We report the largest retrospective, phase IV non-interventional, observational study of ofatumumab therapy in heavily pre-treated patients with poor-prognosis chronic lymphocytic leukemia. Total number of patients was 103; median age was 65 years (range 39-85). Median number of prior lines of therapy was 4 (range 1-13), including, in most cases, rituximab-, fludarabine- and alemtuzumab-based regimens; 13 patients had been allografted. Of 113 adverse events, 28 (29%) were considered to be directly related to ofatumumab. Grade 3-4 toxicities included neutropenia (10%), thrombocytopenia (5%), anemia (3%), pneumonia (17%), and fever (3%). Two heavily pre-treated patients developed progressive multifocal leukoencephalopathy. On an intention-to-treat analysis, the overall response rate was 22% (3 complete response, 1 incomplete complete response). Median progression-free and overall survival times were 5 and 11 months, respectively. This study confirms in a daily-life setting the feasibility and acceptable toxicity of ofatumumab treatment in advanced chronic lymphocytic leukemia. The complete response rate, however, was low. Therefore, treatment with ofatumumab should be moved to earlier phases of the disease. Ideally, this should be done in combination with other agents, as recently approved for ofatumumab plus chlorambucil as front-line treatment for patients unfit for fludarabine. This study is registered at clinicaltrials.gov identifier:01453062.
- MeSH
- chronická lymfatická leukemie diagnóza farmakoterapie mortalita MeSH
- dospělí MeSH
- humanizované monoklonální protilátky MeSH
- indukce remise MeSH
- lidé středního věku MeSH
- lidé MeSH
- monoklonální protilátky aplikace a dávkování škodlivé účinky terapeutické užití MeSH
- opakovaná terapie MeSH
- protinádorové látky aplikace a dávkování škodlivé účinky terapeutické užití MeSH
- rozvrh dávkování léků MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky, fáze IV MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
- Názvy látek
- humanizované monoklonální protilátky MeSH
- monoklonální protilátky MeSH
- ofatumumab MeSH Prohlížeč
- protinádorové látky MeSH
Most myelodysplastic syndromes (MDS)-patients receive multiple red blood cell transfusions (RBCT). Transfusions may cause iron-related toxicity and mortality, influencing outcome after allogeneic HSCT. This prospective non-interventional study evaluated 222 MDS and CMML patients undergoing HSCT. Overall survival (OS), relapse-free survival (RFS), non-relapse mortality (NRM), and relapse incidence (RI) at 36 months were 52%, 44%, 25%, and 31%, respectively. Age, percentage of marrow blasts and severe comorbidities impacted OS. RFS was significantly associated with RBCT burden prior to HSCT (HR: 1.7; p = .02). High ferritin levels had a significant negative impact on OS and RI, but no impact on NRM. Administration of iron chelation therapy prior to HSCT did not influence the outcome, but early iron reduction after HSCT (started before 6 months) improved RFS significantly after transplantation (56% in the control group vs. 90% in the treated group, respectively; p = .04). This study illustrates the impact of RBCT and related parameters on HSCT-outcome. Patients with an expected prolonged survival after transplantation may benefit from early iron reduction therapy after transplantation.
- Klíčová slova
- MDS, allogeneic stem cell transplantation, chelation therapy, phlebotomies, transfusions,
- MeSH
- chelátová terapie MeSH
- dospělí MeSH
- flebotomie MeSH
- homologní transplantace MeSH
- incidence MeSH
- krevní transfuze * MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- myelodysplastické syndromy komplikace epidemiologie mortalita terapie MeSH
- nemoc štěpu proti hostiteli diagnóza etiologie MeSH
- přetížení železem diagnóza etiologie terapie MeSH
- proporcionální rizikové modely MeSH
- senioři MeSH
- transplantace hematopoetických kmenových buněk * škodlivé účinky metody MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
BACKGROUND: Available tacrolimus formulations exhibit substantial inter- and intra-individual variability in absorption and metabolism. The present non-interventional cohort study aimed to assess the tolerability and effectiveness of the once-daily tacrolimus formulation, LCPT, in hepatic allograft recipients in real life. MATERIALS AND METHODS: This study was conducted in Austria and the Czech Republic between July 2016 and August 2019. Patients aged ≥ 18 years old received LCPT per the approved label and local clinical routine. All the participants provided informed consent. Patients newly treated with tacrolimus (de novo) directly after transplantation were observed for six months. The relevant clinical variables were tacrolimus trough level (TL), total daily dose (TDD), number of dose adjustments, kidney and liver function, and tolerability. RESULTS: Of the 70 analyzed patients, 72.9% were male and 85.7% were aged < 65 years old. The mean (SD) time to achieve tacrolimus target TL was 6.4 (4.6) days after 4.4 (4.0) dose adjustments; thereafter, TL remained stable throughout observation at approximately 8 ng/mL. The LCPT TDD at initiation was 8 mg and decreased by a median of 41.4% to 5 mg at 6 months. Liver function continuously improved, and kidney function remained stable. LCPT was well tolerated with 24 adverse events in eight patients (17 related to immunosuppression, mostly mild renal insufficiency, and hematological adverse events); two serious unrelated adverse events were reported (atrial flutter and liver dysfunction). CONCLUSIONS: TL was rapidly attained with few dose adaptations after LCPT initiation in de novo liver transplant patients. Liver function rapidly improved, whereas kidney function remained normal. LCPT was well-tolerated in this population.
- Klíčová slova
- LCPT, extended-release tacrolimus, graft rejection, liver function, liver transplant, real-world evidence, safety, trough level,
- Publikační typ
- časopisecké články MeSH
OBJECTIVES: Smoking has been shown to influence rheumatoid arthritis (RA) severity and reduce response to some anti-tumour necrosis factor (anti-TNF) therapies. CIMDORA assessed the association between cigarette smoking and clinical effectiveness of certolizumab pegol (CZP) in Hungarian, Slovak, and Czech RA patients. METHODS: CIMDORA was a prospective, non-interventional, 104-week study (Feb 2011-Aug 2015). The primary endpoint was association between change in 28-joint Disease Activity Score (DAS28[ESR]) from baseline to Week 12, and baseline cigarette pack-year history. Secondary endpoints included association between change in DAS28(ESR) and daily number of cigarettes smoked. The full analysis set (FAS) included all patients receiving ≥1 dose of CZP with all necessary assessments for the primary endpoint. Treatment-emergent adverse events (TEAEs) were reported for all patients receiving ≥1 dose of CZP. RESULTS: The FAS included 218/273 enrolled patients: 155 Hungarian, 46 Czech and 17 Slovak. Hungarian and Czech patients completed 104 weeks (n=141); Slovak patients completed 52 weeks. Mean change in DAS28(ESR) [SD] at Week 12 (-2.78 [1.47]) was not significantly associated with baseline cigarette pack-year history (slope estimate [SE]: 0.03, 95% confidence interval [CI]: -0.16, 0.21 [p=0.77]). Mean DAS28(ESR) [SD] reductions to Week 52 (-3.33 [1.33]) were not significantly associated with daily number of cigarettes smoked in the previous month (SE: 0.001, CI: -0.05, 0.05 [p=0.95]). Two deaths were reported but neither of them was related to CZP. No new safety signals were identified and the safety profile was consistent with previous CZP studies. CONCLUSIONS: After 104 weeks of CZP treatment, patients demonstrated similar DAS28(ESR) improvements, irrespective of smoking history.
- MeSH
- antirevmatika * terapeutické užití MeSH
- certolizumab pegol terapeutické užití MeSH
- imunoglobuliny - Fab fragmenty MeSH
- kombinovaná farmakoterapie MeSH
- kouření cigaret * MeSH
- lidé MeSH
- methotrexát MeSH
- polyethylenglykoly MeSH
- prospektivní studie MeSH
- revmatoidní artritida * farmakoterapie MeSH
- TNF-alfa MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Česká republika MeSH
- Maďarsko MeSH
- Slovenská republika MeSH
- Názvy látek
- antirevmatika * MeSH
- certolizumab pegol MeSH
- imunoglobuliny - Fab fragmenty MeSH
- methotrexát MeSH
- polyethylenglykoly MeSH
- TNF-alfa MeSH
BACKGROUND: During long-term multiple sclerosis therapy, patient satisfaction with received treatment has considerable impact on treatment outcomes. Here we report the results of a non-interventional real-world study that mapped the treatment patterns of disease-modifying therapy (DMT) and assessed treatment satisfaction with DMT. PATIENTS AND METHODS: The SKARLET study was a non-interventional, cross-sectional study in Slovakia running from May 2016 to March 2017. Patients with relapsing-remitting multiple sclerosis on DMT for ≥3 months and ≤2 years (per local labelling) from 10 multiple sclerosis centers across Slovakia were included. The primary objective was to collect the Treatment Satisfaction Questionnaire for Medication version 9 (TSQM 9) score regarding perceived effectiveness, convenience and overall satisfaction with DMT. RESULTS: The following TSQM 9 scores (mean; 95% confidence interval) were reported from 415 patients: convenience (75.05; 73.49-76.61), effectiveness (68.15; 66.56-69.75) and global satisfaction scale (66.94; 65.26-68.62). All three parameters of the TSQM 9 were analyzed by the route of DMT administration, with infusions best rated for effectiveness and global satisfaction in comparison to oral dosage and injections. For convenience, however, oral dosage forms were appraised highly (82.66; 80.59-84.73) followed by infusions (74.40; 70.12-78.69), while injections were rated as the worst (66.92; 64.81-69.04). The difference of TSQM 9 scores according to the route of DMT administration is statistically significant for convenience (p < 0.001) and global satisfaction (p = 0.004), but not for effectiveness (p = 0.185). CONCLUSION: In the present study, it was confirmed that patients find oral DMTs as most convenient; however, the infusion form of treatment outweighs oral DMTs in global satisfaction and effectiveness. The differences of TSQM 9 scores among DMT dosage forms were significant for convenience and global satisfaction. In conclusion, the results of this detailed survey increase our understanding of RRMS patient population characteristics and patient satisfaction with DMT treatment.
- Klíčová slova
- disease-modifying therapy, multiple sclerosis, real-world, treatment pattern, treatment satisfaction,
- Publikační typ
- časopisecké články MeSH
INTRODUCTION: Psoriasis is a chronic, immune-mediated inflammatory skin disease. Despite the availability of several therapies, many patients affected by this disease remain untreated, do not have adequate response, or suffer from treatment-related toxic effects. It has been shown that the interleukin (IL)-17 pathway plays a key role in the immunopathogenesis of psoriasis. Brodalumab, the first human monoclonal IgG2 antibody that selectively binds to subunit A of the human IL-17 receptor, blocking interactions with a number of cytokines of the IL-17 family, has confirmed fast onset of action, high complete clearance rates, and sustained efficacy. Nevertheless, there is only a limited amount of published real-world evidence (RWE) data. METHODS: This was an open-label, multicenter, real-world, prospective, non-interventional, non-controlled (single-arm) observational study (LIBERO-CZ) assessing the management of moderate to severe psoriasis with brodalumab in daily practice for up to 52 weeks of treatment. RESULTS: Fifty-four patients (70.4% male, mean age 46.9 ± 13.4 years, weight 95.6 ± 22.7 kg, disease duration 18.6 ± 12.7 years) were enrolled and included in the final analysis. Forty-nine of the patients completed the study and five discontinued prematurely; 51.8% of all the enrolled patients were biologic-naïve. At baseline, 28% patients were classified as severe (psoriasis area severity index (PASI) ≥ 20). Overall, the mean PASI decreased by 15.6 from 16.1 (± 5.0) at baseline to 0.5 (± 1.2) at the last visit. The primary endpoint of an absolute PASI ≤ 3 at week 12 (as observed analysis) was achieved by 95.9% of patients. The static Physician's Global Assessment (sPGA) success (defined as clear = 0 and almost clear = 1) at week 52 was achieved by 92.1% of patients. PASI 75, PASI 90, and PASI 100 were achieved by 98.0%, 87.8%, and 75.5% of patients, respectively, after approximately 52 weeks of treatment. The study also recorded very positive results concerning patient-reported outcomes. CONCLUSIONS: LIBERO-CZ confirms the fast onset and high clearance rates of brodalumab in real life in both biologic-naïve and biologic-experienced patients.
- Klíčová slova
- Biological therapy, Brodalumab, LIBERO, Non-interventional study, Plaque psoriasis, Real-world evidence,
- Publikační typ
- časopisecké články MeSH