The use of unequal randomisation ratios in clinical trials: a review

Applications of simple and accessible methods for meta-analysis involving rare events: A simulation study

Meta-analysis of clinical trials targeting rare events face particular challenges when the data lack adequate number of events and are susceptible to high levels of heterogeneity. The standard meta-analysis methods (DerSimonian Laird (DL) and Mantel–Haenszel (MH)) often lead to serious distortions because of such data sparsity. Applications of the methods suited to specific incidence and heterogeneity characteristics are lacking, thus we compared nine available methods in a simulation study. We generated 360 meta-analysis scenarios where each considered different incidences, sample sizes, between-study variance (heterogeneity) and treatment allocation. We include globally recommended methods such as inverse-variance fixed/random-effect (IV-FE/RE), classical-MH, MH-FE, MH-DL, Peto, Peto-DL and the two extensions for MH bootstrapped-DL (bDL) and Peto-bDL. Performance was assessed on mean bias, mean error, coverage and power. In the absence of heterogeneity, the coverage and power when combined revealed small differences in meta-analysis involving rare and very rare events. The Peto-bDL method performed best, but only in smaller sample sizes involving rare events. For medium-to-larger sample sizes, MH-bDL was preferred. For meta-analysis involving very rare events, Peto-bDL was the best performing method which was sustained across all sample sizes. However, in meta-analysis with 20% or more heterogeneity, the coverage and power were insufficient. Performance based on mean bias and mean error was almost identical across methods. To conclude, in meta-analysis of rare binary outcomes, our results suggest that Peto-bDL is better in both rare and very rare event settings in meta-analysis with limited sample sizes. However, when heterogeneity is large, the coverage and power to detect rare events are insufficient. Whilst this study shows that some of the less studied methods appear to have good properties under sparse data scenarios, further work is needed to assess them against the more complex distributional-based methods to understand their overall performances.

Diagnostic Accuracy of Single-plane Biparametric and Multiparametric Magnetic Resonance Imaging in Prostate Cancer: A Randomized Noninferiority Trial in Biopsy-naïve Men

BACKGROUND

Urological guidelines recommend multiparametric magnetic resonance imaging (mpMRI) in men with a suspicion of prostate cancer (PCa). The resulting increase in MRI demand might place health care systems under substantial stress.

OBJECTIVE

To determine whether single-plane biparametric MRI (fast MRI) workup could represent an alternative to mpMRI in the detection of clinically significant (cs) PCa.

DESIGN, SETTING, AND PARTICIPANTS

Between April 2018 and February 2020, 311 biopsy-naïve men aged ≤75 yr with PSA ≤15 ng/ml and negative digital rectal examination were randomly assigned to 1.5-T fast MRI (n = 213) or mpMRI (n = 98).

INTERVENTION

All MRI examinations were classified according to Prostate Imaging-Reporting and Data System (PI-RADS) version 2. Men scored PI-RADS 1-2 underwent 12-core standard biopsy (SBx) and those with PI-RADS 4-5 on fast MRI or PI-RADS 3-5 on mpMRI underwent targeted biopsy in combination with SBx. Equivocal cases on fast MRI (PI-RADS 3) underwent mpMRI and then biopsy according to the findings.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was to compare the detection rate of csPCa in both study arms, setting a 10% difference for noninferiority. The secondary outcome was to assess the role of prostate-specific antigen density (PSAD) in ruling out men who could avoid biopsy among those with equivocal findings on fast MRI.

RESULTS AND LIMITATIONS

The overall MRI detection rate for csPCa was 23.5% (50/213; 95% confidence interval [CI] 18.0-29.8%) with fast MRI and 32.7% (32/98; 95% CI 23.6-42.9%) with mpMRI (difference 9.2%; p = 0.09). The reproducibility of the study could have been affected by its single-center nature.

CONCLUSIONS

Fast MRI followed by mpMRI in equivocal cases is not inferior to mpMRI in the detection of csPCa among biopsy-naïve men aged ≤75 yr with PSA ≤15 ng/ml and negative digital rectal examination. These findings could pave the way to broader use of MRI for PCa diagnosis.

PATIENT SUMMARY

A faster MRI (magnetic resonance imaging) protocol with no contrast agent and fewer scan sequences for examination of the prostate is not inferior to the typical MRI approach in the detection of clinically significant prostate cancer. If our findings are confirmed in other studies, fast MRI could represent a time-saving and less invasive examination for men with suspicion of prostate cancer. This trial is registered at ClinicalTrials.gov as NCT03693703.

Effects of a 6 Week Low-Dose Combined Resistance and Endurance Training on T Cells and Systemic Inflammation in the Elderly

With increasing age, the immune system undergoes a remodeling process, affecting the shift of T cell subpopulations and the development of chronic low-grade inflammation. Clinically, this is characterized by increased susceptibility to infections or development of several diseases. Since lifestyle factors can play a significant role in reducing the hallmarks of immune aging and inflammation, we investigated the effect of a 6 week low-dose combined resistance and endurance training program. Forty participants (70.3 ± 5.0 years) were randomly assigned to either a training (TG) or control group (CG) and performed a controlled low-threshold and care-oriented 6-week-long combined resistance and endurance training program. Changes in anthropometrics as well as strength capacity were measured. In subgroups of TG and CG, T cells and their subpopulations (CD4⁺, CD8⁺, naïve, central, effector memory, T-EMRA) were analyzed by flow cytometry. The changes of various plasma cytokines, chemokines, growth factors and adipokines were analyzed by luminex assays. The exercise program was followed by an increase in strength capacities. Participants of TG showed an increase of the CD4⁺/CD8⁺ T cell ratio over time (p < 0.05). Significant decreases in systemic levels of interleukin (IL-) 6, IL-8, IL-10 and vascular endothelial growth factor (VEGF) (p < 0.05) were observed for participants of TG over time. Even short-term and low-threshold training can reduce some of the hallmarks of immune aging in elderly and thus could be beneficial to stimulate immunity. The specific characteristics of the program make it easily accessible to older people, who may benefit in the longer term in terms of their immunocompetence.

A pilot randomized controlled trial of a group intervention via Zoom to relieve loneliness and depressive symptoms among older persons during the COVID-19 outbreak

While effective in reducing infections, social distancing during the COVID-19 outbreak may carry ill effects on the mental health of older adults. The present study explored the efficacy of a short-term digital group intervention aimed at providing seniors with the tools and skills necessary for improving their coping ability during these stressful times. A total of 82 community-dwelling adults aged between 65 aged 90 (Mage = 72 years, SD = 5.63) were randomized to either an intervention group (n = 64) or a wait-list control group (n = 18). The intervention comprised online guided sessions in small groups in which behavioral and cognitive techniques were learned and practiced via the ZOOM videoconferencing platform. Loneliness and depression levels were measured pre- and post-participation. The results demonstrated a significant improvement in the intervention group in terms of both loneliness and depressive symptoms, compared with the control group. Results of mixed effect models indicated a medium ameliorative effect on loneliness (d = 0.58), while that for depressive symptoms was only marginally significant and smaller in size (d = 0.43). Our intervention presents a relatively simple and effective technique that can be efficiently utilized to support older adults both during emergencies such as the COVID-19 outbreak, as well as in more routine times for older adults who live alone or reside in remote areas.

Effect of high-intensity interval training on cardiometabolic component risks in persons with paraplegia: Protocol for a randomized controlled trial

Individuals with a spinal cord injury (SCI) are at an increased risk of developing cardiovascular disease and present with a multitude of elevated cardiometabolic component risks. Although upper-body exercise appears an effective strategy to improve some of these outcomes, the effectiveness of high-intensity interval training (HIIT) has yet to be determined for this population. Therefore, a randomized controlled trial will be conducted to determine the effectiveness of a 6 week home-based upper-body HIIT intervention on biomarkers of cardiometabolic health in persons with spinal cord injury, in comparison to a control (CON) group. We will recruit 40 individuals with chronic (>1 year post-injury) paraplegia (spinal cord lesion between the second thoracic and second lumbar vertebrae), aged between 18 and 65 years. After baseline testing, participants will be assigned randomly, using a 2:1 allocation, to the home-based exercise intervention (HIIT, n = 26) or control group (CON, n = 14). The HIIT intervention will consist of 30 min of arm crank-based HIIT (60 s intervals at 80-90% peak heart rate) four times per week. Participants in the CON group will be asked to maintain their habitual diet and physical activity patterns over the study period. Baseline and follow-up assessments will be made for determination of body composition, postprandial glycaemic control, fasting blood lipids and systemic inflammation, aerobic capacity, physical activity and energy intake, resting metabolic rate, resting blood pressure, and subjective measures of health and well-being. ClinicalTrials.gov, ID: NCT04397250. Registered on 21 May 2020.

Most randomized controlled trials for psoriasis used placebo comparators despite the availability of effective treatments

BACKGROUND

The availability of effective treatments for psoriasis raises ethical questions about the use of a placebo group in therapeutic trials. We evaluated the use of the placebo over time in such trials.

METHODS

From trials in a living Cochrane review and network meta-analysis for psoriasis, we included trials comparing a biologic to a placebo or other systemic treatment. First, we tested the changes in placebo rate from 2001 to 2019 by linear regression, then constructed networks for 2004-2019 and evaluated the contribution of the placebo to the network meta-analysis estimates per trial and per comparison.

RESULTS

We included 81 trials (36,774 patients). The placebo rate did not decrease significantly over time. The proportion contribution of trials with a placebo decreased from 100% in 2004 to 86% in 2008 and 75% in 2019. However, the proportion contribution of trials without a placebo remained low (from 0% in 2004 to 25% in 2019).

CONCLUSION

The design of future psoriasis trials should be reviewed to improve the number of patients to be included in a placebo group.

Effectiveness of a Brief Psychological Intervention Delivered by Nurse for Depression in Pregnancy: Study Protocol for a Multicentric Randomized Controlled Trial from India

BACKGROUND

Perinatal depression (PD) has important implications for maternal and infant well-being but largely goes undetected. There is a need to develop low-intensity psychosocial interventions applicable to obstetric health care facilities.

OBJECTIVE

To assess the effectiveness of a brief psychological intervention for mild to moderate PD delivered by a nurse as compared to treatment-as-usual (TAU).

METHODS

This study is a randomized, open-label, parallel-group, multicentric trial being conducted in four sites of India. A total of 816 pregnant women with mild to moderately severe depression (Patient Health Questionaire-9 score of 5-19) are being assessed for the effectiveness of the intervention. Participants are randomly allocated to two groups of trial intervention (psychological intervention given by nurse) and TAU. The primary outcome is to compare the proportion of women reporting improvement across both groups. Participants are serially followed-up in each trimester and at 6, 10, 14 weeks, and 6 months postpartum. Secondary outcomes include pregnancy outcomes, feeding practices, physical growth, and immunization status of the infants.

CONCLUSION

It is a prospective pregnancy birth cohort with a robust design and long-term follow-up. This is one of the largest studies utilizing non-specialist health workers for the screening and management of PD. This study also holds promise to cast light on the course and outcome of depression during pregnancy in different parts of India. It is envisaged to help in developing a sound screening and referral-based protocol for obstetric settings.

The effectiveness of smartphone compassion training on stress among Swedish university students: A pilot randomized trial

OBJECTIVE

To investigate the effects of a 6-week smartphone compassion training intervention on mental health.

METHOD

Fifty-seven Swedish university students (mean age = 25, SD = 5) reporting high levels of stress were randomized to compassion training (n = 23), mindfulness (n = 19), or waitlist (n = 15).

RESULT

Multilevel models indicated that both compassion and mindfulness training increased self-compassion compared to the waitlist, while only compassion significantly reduced stress. Between-group effect sizes for compassion compared to waitlist were large for both self-compassion (d = 1.61) and stress (d = 0.94). Compassion and mindfulness did not differ significantly, but effect sizes were in favor of compassion. Secondary outcomes indicated positive effects on emotional awareness, while no effect was found for global psychological distress.

CONCLUSIONS

Our results suggest that compassion training via a smartphone application can improve self-compassion and reduce stress among university students. Future studies in larger clinical samples are warranted.

Postsurgical Electrical Stimulation Enhances Recovery Following Surgery for Severe Cubital Tunnel Syndrome: A Double-Blind Randomized Controlled Trial

BACKGROUND

Patients with severe cubital tunnel syndrome often have poor functional recovery with conventional surgical treatment. Postsurgical electrical stimulation (PES) has been shown to enhance axonal regeneration in animal and human studies.

OBJECTIVE

To determine if PES following surgery for severe cubital tunnel syndrome would result in better outcomes compared to surgery alone.

METHODS

Patients with severe cubital tunnel syndrome in this randomized, double-blind, placebo-controlled trial were randomized in a 1:2 ratio to the control or stimulation groups. Control patients received cubital tunnel surgery and sham stimulation, whereas patients in the stimulation group received 1-h of 20 Hz PES following surgery. Patients were assessed by a blinded evaluator annually for 3 yr. The primary outcome was motor unit number estimation (MUNE) and secondary outcomes were grip and key pinch strength and McGowan grade and compound muscle action potential.

RESULTS

A total of 31 patients were enrolled: 11 received surgery alone and 20 received surgery and PES. Three years following surgery, MUNE was significantly higher in the PES group (176 ± 23, mean + SE) compared to controls (88 ± 11, P < .05). The mean gain in key pinch strength in the PES group was almost 3 times greater than in the controls (P < .05). Similarly, other functional and physiological outcomes showed significantly greater improvements in the PES group.

CONCLUSION

PES enhanced muscle reinnervation and functional recovery following surgery for severe cubital tunnel syndrome. It may be a clinically useful adjunct to surgery for severe ulnar neuropathy, in which functional recovery with conventional treatment is often suboptimal.

Adding flexibility to clinical trial designs: an example-based guide to the practical use of adaptive designs

Adaptive designs for clinical trials permit alterations to a study in response to accumulating data in order to make trials more flexible, ethical, and efficient. These benefits are achieved while preserving the integrity and validity of the trial, through the pre-specification and proper adjustment for the possible alterations during the course of the trial. Despite much research in the statistical literature highlighting the potential advantages of adaptive designs over traditional fixed designs, the uptake of such methods in clinical research has been slow. One major reason for this is that different adaptations to trial designs, as well as their advantages and limitations, remain unfamiliar to large parts of the clinical community. The aim of this paper is to clarify where adaptive designs can be used to address specific questions of scientific interest; we introduce the main features of adaptive designs and commonly used terminology, highlighting their utility and pitfalls, and illustrate their use through case studies of adaptive trials ranging from early-phase dose escalation to confirmatory phase III studies.

Effect of Pod e-Cigarettes vs Cigarettes on Carcinogen Exposure Among African American and Latinx Smokers: A Randomized Clinical Trial

Importance

Fourth-generation nicotine salt pod system (NSPS) electronic cigarettes (e-cigarettes) are the leading class of e-cigarettes. They contain high nicotine concentrations, which may facilitate switching among smokers, but could also lead to increased exposure to nicotine and biomarkers of potential harm. African American and Latinx smokers experience significant tobacco-related health disparities. The potential of NSPS e-cigarettes to reduce smoking-related harm among these groups is unknown.

Objective

To compare the harm reduction potential of NSPS e-cigarette vs combustible cigarettes.

Design, Setting, and Participants

This unblinded randomized clinical trial compared 6 weeks of e-cigarette use vs cigarettes as usual from to 2018 to 2019 among smokers in the San Diego, California, and Kansas City, Missouri, areas. Participants included African American and Latinx adult combustible cigarette smokers who smoked at least 5 cigarettes/d on at least 25 of the past 30 days for at least 6 months and were interested in switching to e-cigarettes. Data were analyzed from September 18, 2019, to September 4, 2020.

Interventions

6 weeks of e-cigarette use in a choice of pod flavors (5% nicotine) along with brief education, training, and action planning to completely switch to e-cigarettes from combustible cigarettes. The control group smoked combustible cigarettes as usual.

Main Outcomes and Measures

The primary outcome was reduction in urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) concentration at week 6. Secondary outcomes were change in urinary cotinine, expired carbon monoxide (CO), respiratory symptoms, lung function, blood pressure, past 7-day consumption of combustible cigarettes, and switching rates (e-cigarette group only) at weeks 2 and 6.

Results

This study included 186 participants, including 92 African American participants and 94 Latinx participants. The mean (SD) age was 43.3 (12.5) years, and 75 (40.3%) were women. Participants smoked a mean (SD) of 12.1 (7.2) cigarettes/d on 6.8 (0.6) d/wk at baseline. A total of 125 participants were randomized to the e-cigarette group and 61 were randomized to the control group. At baseline, median (interquartile range) NNAL was 124 (45-197) pg/mL in the e-cigarette group and 88 (58-197) pg/mL in the control group. At week 6, the e-cigarette group had significantly greater reductions in NNAL (relative risk [RR], 0.36 [95% CI, 0.23-0.54]; P < .001), CO (RR, 0.53 [95% CI, 0.42-0.68]; P < .001), respiratory symptoms (RR, 0.63 [95% CI, 0.47-0.85]; P = .002), and number of cigarettes smoked in the past 7 days among those still smoking (RR, 0.30 [95% CI, 0.20-0.43]; P < .001) than the control group and maintained their cotinine levels (RR, 0.80 [95% CI, 0.58-1.10]; P = .17). Lung function and diastolic and systolic blood pressure remained unchanged and did not differ between groups. For participants randomized to receive e-cigarettes, 32 participants (28.1%) were exclusively using e-cigarettes at week 6, while 66 participants (57.9%) were dual using and 16 participants (14%) resumed exclusively using cigarettes.

Conclusions and Relevance

These findings suggest that e-cigarettes may be an inclusive harm reduction strategy for African American and Latinx smokers.

Trial Registration

ClinicalTrials.gov Identifier: NCT03511001.

Master Protocol Trial Design for Efficient and Rational Evaluation of Novel Therapeutic Oncology Devices

Historically, the gold standard for evaluation of cancer therapeutics, including medical devices, has been the randomized clinical trial. Although high-quality clinical data are essential for safe and judicious use of therapeutic oncology devices, class II devices require only preclinical data for US Food and Drug Administration approval and are often not rigorously evaluated prior to widespread uptake. Herein, we review master protocol design in medical oncology and its application to therapeutic oncology devices, using examples from radiation oncology. Unique challenges of clinical testing of radiation oncology devices (RODs) include patient and treatment heterogeneity, lack of funding for trials by industry and health-care payers, and operator dependence. To address these challenges, we propose the use of master protocols to optimize regulatory, financial, administrative, quality assurance, and statistical efficiency of trials evaluating RODs. These device-specific master protocols can be extrapolated to other devices and encompass multiple substudies with the same design, statistical considerations, logistics, and infrastructure. As a practical example, we outline our phase I and II master protocol trial of stereotactic magnetic resonance imaging–guided adaptive radiotherapy, which to the best of our knowledge is the first master protocol trial to test a ROD. Development of more efficient clinical trials is needed to promote thorough evaluation of therapeutic oncology devices, including RODs, in a resource-limited environment, allowing more practical and rapid identification of the most valuable advances in our field.

Effect of novel technology-enabled multidimensional physical activity feedback in primary care patients at risk of chronic disease - the MIPACT study: a randomised controlled trial

BACKGROUND

Technological progress has enabled the provision of personalised feedback across multiple dimensions of physical activity that are important for health. Whether this multidimensional approach supports physical activity behaviour change has not yet been examined. Our objective was to examine the effectiveness of a novel digital system and app that provided multidimensional physical activity feedback combined with health trainer support in primary care patients identified as at risk of chronic disease.

METHODS

MIPACT was a parallel-group, randomised controlled trial that recruited patients at medium (≥10 and < 20%) or high (≥20%) risk of cardiovascular disease and/or type II diabetes from six primary care practices in the United Kingdom. Intervention group participants (n = 120) received personal multidimensional physical activity feedback using a customised digital system and web-app for 3 months plus five health trainer-led sessions. All participants received standardised information regarding physical activity. Control group participants (n = 84) received no further intervention. The primary outcome was device-based assessment of physical activity at 12 months.

RESULTS

Mean intervention effects were: moderate-vigorous physical activity: -1.1 (95% CI, - 17.9 to 15.7) min/day; moderate-vigorous physical activity in ≥10-min bouts: 0.2 (- 14.2 to 14.6) min/day; Physical Activity Level (PAL): 0.00 (- 0.036 to 0.054); vigorous physical activity: 1.8 (- 0.8 to 4.2) min/day; and sedentary time: 10 (- 19.3 to 39.3) min/day. For all of these outcomes, the results showed that the groups were practically equivalent and statistically ruled out meaningful positive or negative effects (>minimum clinically important difference, MCID). However, there was profound physical activity multidimensionality, and only a small proportion (5%) of patients had consistently low physical activity across all dimensions.

CONCLUSION

In patients at risk of cardiovascular disease and/or type II diabetes, MIPACT did not increase mean physical activity. Using a sophisticated multidimensional digital approach revealed enormous heterogeneity in baseline physical activity in primary care patients, and practitioners may need to screen for low physical activity across dimensions rather than rely on disease-risk algorithms that are heavily influenced by age.

TRIAL REGISTRATION

This trial is registered with the ISRCTN registry ( ISRCTN18008011 ; registration date 31 July 2013).

Study of alteplase for respiratory failure in severe acute respiratory syndrome coronavirus 2/COVID-19: Study design of the phase IIa STARS trial

Background

The coronavirus disease 2019 (COVID-19) pandemic has caused a large surge of acute respiratory distress syndrome (ARDS). Prior phase I trials (non-COVID-19) demonstrated improvement in pulmonary function in patients ARDS using fibrinolytic therapy. A follow-up trial using the widely available tissue-type plasminogen activator (t-PA) alteplase is now needed to assess optimal dosing and safety in this critically ill patient population.

Objective

To describe the design and rationale of a phase IIa trial to evaluate the safety and efficacy of alteplase treatment for moderate/severe COVID-19-induced ARDS.

Patients/Methods

A rapidly adaptive, pragmatic, open-label, randomized, controlled, phase IIa clinical trial will be conducted with 3 groups: intravenous alteplase 50 mg, intravenous alteplase 100 mg, and control (standard-of-care). Inclusion criteria are known/suspected COVID-19 infection with PaO2/FiO2 ratio <150 mm Hg for > 4 hours despite maximal mechanical ventilation management. Alteplase will be delivered through an initial bolus of 50 mg or 100 mg followed by heparin infusion for systemic anticoagulation, with alteplase redosing if there is a >20% PaO2/FiO2 improvement not sustained by 24 hours.

Results

The primary outcome is improvement in PaO2/FiO2 at 48 hours after randomization. Other outcomes include ventilator- and intensive care unit-free days, successful extubation (no reintubation ≤3 days after initial extubation), and mortality. Fifty eligible patients will be enrolled in a rapidly adaptive, modified stepped-wedge design with 4 looks at the data.

Conclusion

Findings will provide timely information on the safety, efficacy, and optimal dosing of t-PA to treat moderate/severe COVID-19-induced ARDS, which can be rapidly adapted to a phase III trial (NCT04357730; FDA IND 149634).

Patterns of Growth and Nutrition From Birth to 6 Months in Infants With Complex Congenital Cardiac Defects

BACKGROUND

Infants with complex congenital heart defects (CCHDs) experience alterations in growth that develop following surgical intervention and persist throughout early infancy, but the roles of nutritional intake and method of feeding require further exploration as their roles are not fully explained.

OBJECTIVES

The purpose of this study was to characterize trends in growth and nutritional intake during the first 6 months of life in infants with CCHD.

METHODS

We conducted a secondary analysis of growth and nutritional data from a pilot study designed to test the feasibility of nurse-guided participatory intervention with parents of infants with CCHD. Measures included demographic data, anthropometric data at birth, hospital discharge, and 6 months of age, nutritional intake at 2 and 6 months of age from parent-completed 24-hour nutrition diaries, and assessment of oral-motor skills between 1 and 2 months of age. Descriptive statistics and correlation and group differences were examined.

RESULTS

Data for 28 infants were analyzed. Infants demonstrated a decrease in weight-for-age z score (WAZ) and length-for-age z score (LAZ) from birth to hospital discharge and an increase in WAZ and LAZ by 6 months of age. Many of the infants developed failure to thrive. Across the study period, one third of the infants were receiving enteral nutrition. Infants who were orally fed had better growth WAZ and LAZ at 6 months of age when compared to infants who were enterally fed.

DISCUSSION

Infants with CCHD exhibit growth faltering throughout early infancy. Reliance on enteral nutrition did not improve growth outcomes in these infants. Findings suggest nutritional intake may not be enough to meet the nutrient requirements to stimulate catch-up growth.

Reducing Risk Behavior with Family-Centered Prevention During the Young Adult Years

Family-centered prevention is effective at reducing risk behavior throughout the life span and promoting healthy development. Despite research that suggests parents continue to play a significant role in the lives of their children during emerging adulthood, very few studies have examined effective family-centered strategies for preventing risk behavior in young adults. Typical prevention efforts for this age group have focused on college students and substance use prevention, with no integration of families or systems of support that may sustain the effects of the intervention. In this study, we evaluated a version of the Family Check-Up (FCU) that was adapted for young adults and their families, the Young Adult Family Check-Up (YA-FCU). Families were randomly assigned to receive the FCU or school as usual during the middle school years. Ten years later, they were offered the YA-FCU, which was adapted for families of emerging adult children. Intent-to-treat and complier average causal effect analyses were used to examine change in young adult risk behavior approximately 1 year after receiving the YA-FCU. Analyses indicated that random assignment alone or simple engagement was not associated with reductions in young adult risk behavior. However, dose-response analyses indicated that the more hours that youth and families were engaged in the YA-FCU, the greater the reductions in young adult risk behavior relative to those who did not engage or engaged very little in the intervention, resulting in a medium effect size of the YA-FCU on risk behavior.

Evaluation of Olfactory and Gustatory Functions in Patients With Fibromyalgia Syndrome: Its Relationship With Anxiety, Depression, and Alexithymia

Objectives

This study aims to evaluate smell and taste functions in patients with fibromyalgia syndrome (FMS) and the relationship between smell and taste functions, anxiety, depression, alexithymia, and quality of life (QoL).

Patients and methods

This cross-sectional study included 30 patients with FMS (3 males, 27 females; mean age 46.0±8.5 years; range, 18 to 70 years) and 20 age- and sex-matched healthy participants (2 males, 18 females; mean age 45.7±10.0 years; range, 18 to 70 years). Fibromyalgia Impact Questionnaire (FIQ) was applied to FMS patients. Hamilton Anxiety Scale, Depression Scale, Toronto Alexithymia Scale, and EuroQol Questionnaire Five-Dimensions (EQ-5D) were applied to all participants. Sniffin' Sticks test was used for olfactory function analysis while taste strips were used for gustatory function analysis.

Results

The FMS patients had higher anxiety, depression, and alexithymia while lower QoL scores. Olfactory and gustatory function test scores were lower in FMS patients. Total olfactory function scores were 25.96 and 36.40 for FMS and control groups, respectively. For taste function, they were 9.93 and 13.55, respectively. These scores were negatively correlated with anxiety, depression, and alexithymia scores whereas positively correlated with EQ-5D index score. There was no significant correlation with FIQ score.

Conclusion

Anxiety and depression are common symptoms of FMS. Patients with FMS had altered olfactory and gustatory functions and these impairments were correlated with their anxiety and depression. Further studies with larger sample sizes including functional magnetic resonance imaging evaluation should be performed.

The Role of Clinical Examination in Midface Volume Correction Using Hyaluronic Acid Fillers: Should Patients Be Stratified by Skin Thickness?

Background

Aesthetic physicians have several hundred injectable products to select from. Due to differences in their manufacturing technology, these products display varying biophysical qualities, such as their cohesivity and lift capacity. Currently, there is no guidance to objectively selecting the best product for a particular patient. Therefore, an algorithmic approach is required to take specific skin characteristics into consideration.

Objectives

To evaluate (1) whether subjects seeking injectable treatments for midfacial volume loss and/or contour deficiency can be stratified based on specific skin characteristics (eg, thickness, fat quantity, bony structure) and (2) whether particular hyaluronic acid fillers perform best when used in such particular strata.

Methods

This was a prospective, Phase IV, open-label, single-center clinical trial. Thirty female patients with midface/cheek volume loss and/or contour deficiency were recruited (mean age, 53.5 years; SD, 12.57; range, 35–75 years). Subjects were treated with either Restylane Lyft (HA_L) or Restylane Volyme (HA_V) and followed for 4 months post-injection. Treatment allocation was based on the treating physician’s clinical evaluation and compared with ultrasound evaluation. Ultrasound images were used to confirm stratification. Safety and efficacy assessments were performed at each study visit: baseline, week 2, week 4, week 8, and week 16. Subgroup analyses evaluated whether particular strata performed best when treated with specific products.

Results

The 2 investigative products varied in their efficacy, depending on the characteristics of the subject.

Conclusions

The use of a treatment algorithm may improve outcomes for patients seeking injectable treatments for midfacial volume loss and contour deficiencies.

Level of Evidence: 2

Potential for smart food products in rural Myanmar: use of millets and pigeonpea to fill the nutrition gap

BACKGROUND

The present study examined the potential for 'Smart Food' with respect to contributing to the Sustainable Development Goal 2 of ending malnutrition by 2030, using a small-scale capacity building case study in Oe Be Village, Myingyan district, Mandalay region, Myanmar. Within the study site, refined white rice is the major staple, followed by vegetables and animal source food in inadequate quantities. The protein intake in this particular dry zone community meets only 50% of the daily requirement and even less for those children aged less than 23 months. Therefore, to determine the acceptance and opportunity for legumes and millets which are produced locally, nutritious formulations were introduced for various age groups. In addition, a sensory evaluation of the recipes was conducted to test the acceptance of the nutritious products.

RESULTS

Two weeks of the inclusion of millets and pigeonpea in the diets of children aged 6-23 months had a positive impact on wasting, stunting and underweight (P = 0.002, 0.014 and 0.023, respectively). Moreover, the acceptability of these new food products by the children was found to be high. These results indicate an unexplored opportunity for specific millets rich in iron, zinc and calcium, as well as for pigeonpea rich in protein, if prepared in a culturally acceptable way.

CONCLUSION

The impact and acceptability of this small scale and short-term intervention indicate the potential for Smart Food products in filling the nutrition gap arising from the traditional food consumption habits in the dry zones of Myanmar. © 2019 Society of Chemical Industry.

Double J stent removal in paediatric patients by Vellore Catheter Snare technique: a randomised control trial

BACKGROUND

Double J (DJ) stents placed at the end of paediatric urological procedures require another cystoscopy under general anaesthesia for removal. The second author developed a reproducible technique for snaring the DJ stent using an infant feeding tube (6-Fr or 8-Fr) and a 3-0 polypropylene suture per urethra. Having demonstrated the proof of concept, ethical clearance was obtained for an institutional randomised controlled trial.

OBJECTIVE

The aim of the study was (1) to describe the Vellore Catheter Snare (VeCS) technique for DJ stent removal, (2) to study the efficacy of the technique and (3) to compare the costs of VeCS technique with cystoscopy on an intention-to-treat basis.

STUDY DESIGN

The study design was that of a randomised control trial with parallel groups as a non-inferiority study.

RESULTS

Forty children with unilateral indwelling DJ stents were enrolled from January to August 2018. They were randomised by unequal allocation (1:3) to cystoscopic and VeCS technique removal arms. The VeCS technique and cystoscopy were successful in 86.67% (26/30) and in 100% (10/10) cases, respectively, with no statistically significant difference in the outcome (p = 0.223). The average cost for cystoscopic removal of the stent was INR 14,579 and was INR 5636.5 for the VeCS technique (on an intention-to-treat basis).

DISCUSSION

While per-urethral catheterisation is an outpatient/ward procedure in children, cystoscopy is not. Other techniques such as extraction strings and magnetic stents with their extraction device were found to have certain disadvantages. The VeCS technique, using common disposables, circumvented the need for inpatient admission, disinfected equipment usage and operation theatre time in 87% children, thereby reducing the costs incurred by the patient.

CONCLUSION

The VeCS technique for DJ stent removal is a practical low-cost safe alternative to cystoscopic removal of DJ stents in children. Although the technique has a high success rate, it still needs the backup option of cystoscopy under general anaesthesia.

An introduction to clinical trial design

Clinicians and other decision makers in healthcare use results from clinical trials to inform practice. Interpretation of clinical trial results can be challenging, as weaknesses in trial design, data collection, analysis or reporting, can compromise the usefulness of results. A good working knowledge of clinical trial design is essential to expertly interpret and determine the validity and generalizability of the results. This manuscript will give a brief overview of clinical trial design including the strengths and limitations of various approaches. The focus will be on confirmatory clinical trials.

Extended-release Naltrexone Improves Viral Suppression Among Incarcerated Persons Living with HIV and Alcohol use Disorders Transitioning to the Community: Results From a Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To determine whether extended-release naltrexone (XR-NTX) would improve or maintain viral suppression (VS) among incarcerated individuals with HIV and alcohol use disorders (AUDs) transitioning to the community.

DESIGN

A randomized, double-blind, placebo-controlled trial was conducted among incarcerated individuals with HIV and AUDs transitioning to the community from 2010 through 2016.

METHODS

Eligible participants (N = 100) were randomized 2:1 to receive 6 monthly injections of XR-NTX (n = 67) or placebo (n = 33) starting at release and continued for 6 months. The primary and secondary outcomes were the proportion that maintained or improved VS at <200 and <50 copies per milliliter from baseline to 6 months, respectively, using an intention-to-treat analysis.

RESULTS

Participants allocated to XR-NTX improved VS from baseline to 6 months for <200 copies per milliliter (48.0%-64.2%, P = 0.024) and for <50 copies per milliliter (31.0%-56.7%, P = 0.001), whereas the placebo group did not (<200 copies/mL: 64%-42.4%, P = 0.070; <50 copies/mL: 42.0%-30.3%, P = 0.292). XR-NTX participants were more likely to achieve VS than the placebo group at 6 months (<200 copies/mL: 64.2% vs. 42.4%; P = 0.041; <50 copies/mL: 56.7% vs. 30.3%; P = 0.015). XR-NTX independently predicted VS [<200 copies/mL: adjusted odds ratio (aOR) = 2.68, 95% confidence interval (CI) = 1.01 to 7.09, P = 0.047; <50 copies/mL: aOR = 4.54; 95% CI = 1.43 to 14.43, P = 0.009] as did receipt of ≥3 injections (<200 copies/mL: aOR = 3.26; 95% CI = 1.26 to 8.47, P = 0.010; <50 copies/mL: aOR = 6.34; 95% CI = 2.08 to 19.29, P = 0.001). Reductions in alcohol consumption (aOR = 1.43, 95% CI = 1.03 to 1.98, P = 0.033) and white race (aOR = 5.37, 95% CI = 1.08 to 27.72, P = 0.040) also predicted VS at <50 copies per milliliter.

CONCLUSIONS

XR-NTX improves or maintains VS after release to the community for incarcerated people living with HIV and AUDs.

Patient-initiated versus fixed-interval patient-reported outcome-based follow-up in outpatients with epilepsy: a pragmatic randomized controlled trial

BACKGROUND

The use of patient-reported outcome (PRO) could potentially contribute to the reorganization of the health care system. AmbuFlex is a PRO system used in remote patient monitoring, in which questionnaires are sent to patients at fixed intervals. The PRO data are used by clinicians to decide whether patients need clinical attention. Better self-management and cost-saving follow-up activities may be achieved by letting patients initiate need of contact. We evaluated the effects of patient-initiated PRO-based outpatient follow-up on health care resource utilization, quality of care, and the patient perspective.

METHODS

We conducted a parallel two-arm pragmatic randomized controlled trial at the Department of Neurology, Aarhus University Hospital, Denmark. Outpatients with epilepsy (≥ 15 years old), attending fixed-interval PRO-based follow-up with web-based questionnaires, were randomly assigned in a ratio of 0.55:0.45 to either 1) patient-initiated PRO-based follow-up (open access telePRO) or 2) fixed-interval PRO-based follow-up (standard telePRO). The primary outcome was the number of outpatient hospital contacts related to epilepsy retrieved from a regional registry. Hospitals admissions and emergency room visits were also assessed. Secondary self-reported outcomes including general health, well-being, health literacy, self-efficacy, number of seizures, side effects, confidence, safety, and satisfaction were retrieved from questionnaires. Data were analyzed by the intention-to-treat and per-protocol approaches.

RESULTS

Between January 2016 and July 2016, 593 patients were randomized to either open access telePRO (n = 346) or standard telePRO (n = 247). At 18 months, no statistically significant differences were found between the arms regarding number of telephone consultations or outpatient visits. Patients in the open access arm had a slightly lower, statistically significant number of emergency room visits than patients in the standard arm. Self-reported mental well-being in the open access arm was slightly, statistically significantly lower than in the standard arm. Other secondary outcomes did not differ statistically significantly between arms.

CONCLUSION

This study did not find, as hypothesized, less use of health care resources or improved patient self-management or satisfaction in the patient-initiated PRO-based initiative compared to fixed-interval PRO-based follow-up. Patient-initiated PRO-based follow-up may be used as an alternative to fixed-interval PRO-based follow-up in patients who prefer this approach, but there is insufficient evidence for recommending a system-wide shift to patient-initiated PRO-based follow-up.

TRIAL REGISTRATION

Registered 4 February 2016 with ClinicalTrials.gov: NCT02673580 .

A Smartphone App for Improving Mental Health through Connecting with Urban Nature

In an increasingly urbanised world where mental health is currently in crisis, interventions to increase human engagement and connection with the natural environment are one of the fastest growing, most widely accessible, and cost-effective ways of improving human wellbeing. This study aimed to provide an evaluation of a smartphone app-based wellbeing intervention. In a randomised controlled trial study design, the app prompted 582 adults, including a subgroup of adults classified by baseline scores on the Recovering Quality of Life scale as having a common mental health problem (n = 148), to notice the good things about urban nature (intervention condition) or built spaces (active control). There were statistically significant and sustained improvements in wellbeing at one-month follow-up. Importantly, in the noticing urban nature condition, compared to a built space control, improvements in quality of life reached statistical significance for all adults and clinical significance for those classified as having a mental health difficulty. This improvement in wellbeing was partly explained by significant increases in nature connectedness and positive affect. This study provides the first controlled experimental evidence that noticing the good things about urban nature has strong clinical potential as a wellbeing intervention and social prescription.

Best (but oft forgotten) practices: sample size planning for powerful studies

Given recent concerns regarding replicability and trustworthiness in several areas of science, it is vital to encourage researchers to conduct statistically rigorous studies. Achieving a high level of statistical power is one particularly important domain in which researchers can improve the quality and reproducibility of their studies. Although several factors influence statistical power, appropriate sample size planning is often under the control of the researcher and can result in powerful studies. However, the process of conducting sample size planning to achieve a specified level of desired statistical power is often complex and the literature can be difficult to navigate. This article aims to provide an approachable overview of statistical power and sample size planning, with emphasis on why statistical power is important for high-quality science. Thorough examples relevant to nutrition researchers are included to illustrate the process of sample size planning. Special consideration is also given to issues that may arise when conducting sample size planning in practice. The overarching goal is to provide nutrition researchers with the tools and expertise needed to conduct effective sample size planning for future studies.

Rethinking the Gold Standard With Multi-armed Bandits: Machine Learning Allocation Algorithms for Experiments

In experiments, researchers commonly allocate subjects randomly and equally to the different treatment conditions before the experiment starts. While this approach is intuitive, it means that new information gathered during the experiment is not utilized until after the experiment has ended. Based on methodological approaches from other scientific disciplines such as computer science and medicine, we suggest machine learning algorithms for subject allocation in experiments. Specifically, we discuss a Bayesian multi-armed bandit algorithm for randomized controlled trials and use Monte Carlo simulations to compare its efficiency with randomized controlled trials that have a fixed and balanced subject allocation. Our findings indicate that a randomized allocation based on Bayesian multi-armed bandits is more efficient and ethical in most settings. We develop recommendations for researchers and discuss the limitations of our approach.

The feasibility and acceptability of morning versus evening exercise for overweight and obese adults: A randomized controlled trial

BACKGROUND

The time of day that people exercise could have an influence on the efficacy of exercise for weight loss, via differences in adherence and/or physiological adaptations. However, there is currently no evidence to support an optimal time of day for exercise to maximise efficacy.

PURPOSE

To examine the feasibility and acceptability of prescribed morning and evening exercise.

METHODS

Twenty inactive, overweight adults aged 18-60 years were recruited for a 12-week intervention and randomized to one of three groups using a 2:2:1 random allocation ratio: i) morning exercise (AM; n = 9); ii) evening exercise (PM; n = 7); or iii) waitlist control (CON; n = 4). Exercise groups were prescribed self-paced walking or running on a treadmill to achieve a weekly total of 250 min. Feasibility and acceptability data were collected, and physiological and behavioural outcomes associated with energy balance were measured at baseline, mid- and post-intervention.

RESULTS

Attrition was low (n = 2 dropped out), with high measurement completion rates (>80%). The intervention groups had high adherence rates to exercise sessions (94% and 87% for the AM and PM groups, respectively). No adverse events resulting from the intervention were reported. Both intervention groups displayed improvements to their cardiometabolic risk profile; cardiorespiratory fitness improved by 5.2 ± 4.7, and 4.6 ± 4.5 mL kg-1.min-1 and body fat percentage reduced by 1.2 ± 1.4, and -0.6 ± 1.2% for AM and PM groups, respectively.

CONCLUSION

This feasibility study provides evidence that morning and evening exercise interventions are feasible, and also provides justification for a large-scale randomized controlled trial.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000457448p, 7/4/2016).

WhatsApp embedded in routine service delivery for smoking cessation: effects on abstinence rates in a randomized controlled study

Background

The demand for smoking cessation services has risen in Turkey, as smokers planning to quit reached 35% in 2012. Communication technologies are used globally to support quitters, yet their integration to health services is rare. This study aims to evaluate the effect of support messages through WhatsApp application added to the usual care of a university hospital cessation unit, as compared to usual care alone, on abstinence rates at first month.

Methods

A randomized controlled intervention study was conducted with 132 patients applying to Ege University Hospital’s Department of Public Health Smoking Cessation Clinic, between March and July 2017. Intervention content was prepared and 60 WhatsApp messages about having a plan of action and preventing relapse were developed through expert panels. These messages lasted for 3 months and follow-ups continued for 6 months. The primary outcome was abstinence rate at 1st month post target quit day. As secondary outcomes; the continuous abstinence rates at 3rd and 6th months, number of follow-ups, change in weight and continuity of medication were evaluated. Intention-to-treat analysis was used.

Results

Abstinence rate at 1st month was 65.9% in the intervention group and 40.9% in the control group (p = 0.007); 50.0 and 30.7% at 3rd month and 40.9 and 22.7% at 6th month, consecutively (both p < 0.05). Being in the intervention group increased abstinence rate by 3.50 (OR, 95% CI = 1.30–9.44) times in the 1st month. When controlled for all other factors in the multivariate logistic regression, the intervention was the only variable significantly associated with abstinence. For secondary outcomes, the intervention increased abstinence rate by 2.50 (OR, 95% CI = 1.08–6.40) times in the 3rd and 2.31 (OR, 95% CI = 1.03–5.16) times in the 6th month. In the intervention group, the number of follow-ups and face-to-face follow-ups were higher at 1st and 3rd months and continuity of medication was longer at 3rd month.

Conclusions

WhatsApp support embedded in cessation service delivery increases the abstinence rate and has favorable effects on follow-up.

Trial registration

This trial is retrospectively registered online at ClinicalTrials.gov with the identifier NCT03714971.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6727-z) contains supplementary material, which is available to authorized users.

A pilot randomised controlled trial of physical activity facilitation for older adults: feasibility study findings

Background

More people are living longer lives leading to a growth in the population of older adults, many of whom have comorbidities and low levels of physical function. Physical activity in later life can prevent or delay age-related disability. Identifying a cost-effective means of increasing physical activity in older adults therefore remains an important public health priority.

Physical Activity Facilitation (PAF) is an intervention shown to increase physical activity in adults with depression. The PAF model was modified for a population of older adults at risk of disability. This study aimed to assess the feasibility of undertaking a definitive RCT of the PAF intervention in the target population.

Methods

A pilot randomised controlled trial (RCT) was delivered through primary care. Patients at risk of disability and who were not meeting recommended levels of physical activity were recruited through postal invitation and direct approach in the practice waiting room. Those meeting eligibility criteria were enrolled and randomised at a 2:1 ratio to the PAF intervention and control. Behaviour change techniques were used by facilitators with participants over the telephone and face-to-face for 6 months. Outcome measures including physical function, physical activity, depression, social support, and quality of life were collected at baseline and at 6 months.

Results

A high proportion of patients responded to the initial invitation (68%), yet many were ineligible due to high levels of self-reported physical activity and baseline physical function. Fifty-one participants were recruited to the trial, with an average age of 74 years (range 65–89), and there were high rates of adherence and retention to the study (94% follow-up at 6 months). The majority of outcome data collected from participants was complete; however, the validated scale used to measure self-reported physical activity was associated with high levels of missing data.

Conclusions

The findings of this pilot RCT suggest that it is feasible to deliver a definitive RCT of the PAF intervention in this population. Further work is required to improve the efficiency of recruitment and to minimise missing data from self-reported physical activity measures.

Trial registration

Current controlled trials ISRCTN80470273. Registered 25 October 2013.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0414-9) contains supplementary material, which is available to authorized users.

Sample size calculation in multi-centre clinical trials

Background

Multi-centre randomized controlled clinical trials play an important role in modern evidence-based medicine. Advantages of collecting data from more than one site are numerous, including accelerated recruitment and increased generalisability of results. Mixed models can be applied to account for potential clustering in the data, in particular when many small centres contribute patients to the study. Previously proposed methods on sample size calculation for mixed models only considered balanced treatment allocations which is an unlikely outcome in practice if block randomisation with reasonable choices of block length is used.

Methods

We propose a sample size determination procedure for multi-centre trials comparing two treatment groups for a continuous outcome, modelling centre differences using random effects and allowing for arbitrary sample sizes. It is assumed that block randomisation with fixed block length is used at each study site for subject allocation. Simulations are used to assess operation characteristics such as power of the sample size approach. The proposed method is illustrated by an example in disease management systems.

Results

A sample size formula as well as a lower and upper boundary for the required overall sample size are given. We demonstrate the superiority of the new sample size formula over the conventional approach of ignoring the multi-centre structure and show the influence of parameters such as block length or centre heterogeneity. The application of the procedure on the example data shows that large blocks require larger sample sizes, if centre heterogeneity is present.

Conclusion

Unbalanced treatment allocation can result in substantial power loss when centre heterogeneity is present but not considered at the planning stage. When only few patients by centre will be recruited, one has to weigh the risk of imbalance between treatment groups due to large blocks and the risk of unblinding due to small blocks. The proposed approach should be considered when planning multi-centre trials.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0602-y) contains supplementary material, which is available to authorized users.

Work and SCI: a pilot randomized controlled study of an online resource for job-seekers with spinal cord dysfunction

STUDY DESIGN

A prospective, parallel randomized controlled trial (RCT).

OBJECTIVES

To test the preliminary effects of an online resource targeted to job-seekers with spinal cord injury or disorder (SCI/D), and to determine the feasibility of proceeding to a full-scale RCT.

SETTING

A community cohort in Australia.

METHODS

Forty-eight adults (M = 42 years, SD = 10.95, 27 males) were randomized to receive 4-weeks access to the Work and SCI resource (n = 25) or to a wait-list control group (n = 23). The Work and SCI intervention involved six stand-alone learning modules which provided job-searching and career-planning information through text, videos, and interactive activities. Self-report measures were administered at baseline and after 4 weeks: Job Procurement Self-Efficacy Scale (JSES), Life Orientation Test-Revised (LOT-R), and Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Online usage data identified high uptake of the Work and SCI resource, although study attrition was problematic. Intention-to-treat analyses failed to reach statistical significance, whereas complete data revealed a significant interaction effect for optimism (LOT-R).

CONCLUSION

Further research to develop and enhance Work and SCI is indicated. Remediable strategies to optimize recruitment and statistical power in a future definitive RCT are discussed.

SPONSORSHIP

This project was funded by the auDA Foundation (project 16019).

Using New and Innovative Technologies to Assess Clinical Stage in Early Intervention Youth Mental Health Services: Evaluation Study

Background

Globally there is increasing recognition that new strategies are required to reduce disability due to common mental health problems. As 75% of mental health and substance use disorders emerge during the teenage or early adulthood years, these strategies need to be readily accessible to young people. When considering how to provide such services at scale, new and innovative technologies show promise in augmenting traditional clinic-based services.

Objective

The aim of this study was to test new and innovative technologies to assess clinical stage in early intervention youth mental health services using a prototypic online system known as the Mental Health eClinic (MHeC).

Methods

The online assessment within the MHeC was compared directly against traditional clinician assessment within 2 Sydney-based youth-specific mental health services (headspace Camperdown and headspace Campbelltown). A total of 204 young people were recruited to the study. Eligible participants completed both face-to-face and online assessments, which were randomly allocated and counterbalanced at a 1-to-3 ratio. These assessments were (1) a traditional 45- to 60-minute headspace face-to-face assessment performed by a Youth Access Clinician and (2) an approximate 60-minute online assessment (including a self-report Web-based survey, immediate dashboard of results, and a video visit with a clinician). All assessments were completed within a 2-week timeframe from initial presentation.

Results

Of the 72 participants who completed the study, 71% (51/72) were female and the mean age was 20.4 years (aged 16 to 25 years); 68% (49/72) of participants were recruited from headspace Camperdown and the remaining 32% (23/72) from headspace Campbelltown. Interrater agreement of participants’ stage, as determined after face-to-face assessment or online assessment, demonstrated fair agreement (kappa=.39, P<.001) with concordance in 68% of cases (49/72). Among the discordant cases, those who were allocated to a higher stage by online raters were more likely to report a past history of mental health disorders (P=.001), previous suicide planning (P=.002), and current cannabis misuse (P=.03) compared to those allocated to a lower stage.

Conclusions

The MHeC presents a new and innovative method for determining key clinical service parameters. It has the potential to be adapted to varied settings in which young people are connected with traditional clinical services and assist in providing the right care at the right time.

Heterogeneous perception of the ethical legitimacy of unbalanced randomization by institutional review board members: a clinical vignette-based survey

Background

Institutional review boards must guarantee the ethical acceptability of a randomized controlled trial before it is conducted. However, some may regard an unbalanced randomization ratio as reflecting an absence of uncertainty between the groups being compared. The objective was to assess institutional review board members’ perceptions of whether unbalanced randomization in randomized controlled trials is justified and ethically acceptable.

Methods

Institutional review board members worldwide completed a survey involving clinical vignettes modeling situations classically advocated to explain the use of unbalanced randomization. Institutional review board members were asked whether unbalanced randomization was justified and ethically sound. Answers were collected by using visual analog scales. Data were analyzed by principal component analysis, and a hierarchical ascending classification was created. Verbatim answers were assessed by qualitative content analysis.

Results

We analyzed responses from 148 institutional review board members. Three classes of respondents were identified: class 1 (n = 58; 39.2%), mostly skeptics who disagreed with unbalanced randomization, whatever the justification; class 2 (n = 46; 31.1%), believers who considered that unbalanced randomization was acceptable whatever the justification, except cost; and class 3 (n = 44; 29.7%), circumstantial believers for whom unbalanced randomization may be justified for methodological and safety issues but not cost or ethical issues. When institutional review board members were asked whether unbalanced randomization respected the equipoise principle, the mean quotation was low (4.5 ± 3.3 out of 10), especially for class 1 members.

Conclusions

Institutional review board members perceive unbalanced randomization heterogeneously in terms of its justification and its ethical validity.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2822-1) contains supplementary material, which is available to authorized users.

Using technology to support care in gestational diabetes mellitus: Quantitative outcomes of an exploratory randomised control trial of adjunct telemedicine for gestational diabetes mellitus (TeleGDM)

AIMS

The increasing incidence and prevalence of gestational diabetes mellitus (GDM) on a background of limited resources calls for innovative approaches healthcare provision. Our aim was to explore the effects of telemedicine supported GDM care on a range of health service utilisation and maternal and foetal outcomes.

METHODS

An exploratory randomised controlled trial of adjunct telemedicine support in the management of insulin-treated GDM compared to usual care control. Outcomes included health service use, maternal and foetal clinical outcomes as well as costs. Groups were compared on outcomes and Poisson and Cox regression analysis were performed for predictors of health service utilisation, glycaemic control and costs.

RESULTS

95 participants were recruited (intervention n = 61, control n = 34). There were no differences between the groups in number of face-to-face appointments (median (IQR) intervention = 8(7), control = 8(6), p = 0.843), rates of caesareans, macrosomia, large for gestational age, special care nursery admission or newborn birth-weight. The intervention had no impact on total (IRR = 1.04, p = 0.596) or face-to-face (IRR = 1.09, p = 0.257) clinic appointments or service provider costs. Participants receiving the intervention reached optimum glycaemic control quicker: mean (SD) 4.3(4.2) weeks vs. 7.6(4.5) weeks, p = 0.0001). Telemedicine was a significant predictor of better glycaemic control (HR = 1.71(95%CI: 1.11, 2.65, p = 0.015).

CONCLUSIONS

Telemedicine support for GDM care showed no impact on service utilisation and costs. The intervention produced similar GDM clinical outcomes as usual care and posed no added risk to clinical quality of care. The intervention may be associated with fewer insulin dose titrations and participants achieved optimum glycaemic control sooner.

A Randomized Controlled Trial of Healthy Families: 6-Month and 1-Year Follow-Up

Home visitation research remains on the forefront as policy makers look to evidence for programs they believe are worthy of investment, particularly in terms of child abuse prevention. A randomized controlled trial (N = 245) of the Healthy Families Arizona home visitation program was conducted. Outcomes were assessed across several key domains related to child abuse and neglect: safety and resources, parenting attitudes and behaviors, health and maternal outcomes, and mental health and coping. Findings revealed significant differences between the groups at both 6-month and 1-year follow-up assessments on use of resources, mobilizing resources, home environment, subsequent pregnancy, positive affect, and problem solving favoring the Healthy Families group. A significant difference was also found between the groups on total violence measured at the 1-year follow-up favoring the Healthy Families group. A qualitative linguistic inquiry and word count analysis was conducted of parent's descriptions of their children and their parenting experiences. Results again revealed significant differences between the groups in narrative descriptions that favored the Healthy Families group. Implications of these findings are discussed in light of the existing evidence for home visitation programs.

Implementing Optimal Designs for Dose-Response Studies Through Adaptive Randomization for a Small Population Group

In dose-response studies with censored time-to-event outcomes, D-optimal designs depend on the true model and the amount of censored data. In practice, such designs can be implemented adaptively, by performing dose assignments according to updated knowledge of the dose-response curve at interim analysis. It is also essential that treatment allocation involves randomization-to mitigate various experimental biases and enable valid statistical inference at the end of the trial. In this work, we perform a comparison of several adaptive randomization procedures that can be used for implementing D-optimal designs for dose-response studies with time-to-event outcomes with small to moderate sample sizes. We consider single-stage, two-stage, and multi-stage adaptive designs. We also explore robustness of the designs to experimental (chronological and selection) biases. Simulation studies provide evidence that both the choice of an allocation design and a randomization procedure to implement the target allocation impact the quality of dose-response estimation, especially for small samples. For best performance, a multi-stage adaptive design with small cohort sizes should be implemented using a randomization procedure that closely attains the targeted D-optimal design at each stage. The results of the current work should help clinical investigators select an appropriate randomization procedure for their dose-response study.

Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention

Adults who complete an advance directive (AD) are not consistently offered information about the risks, benefits, or alternatives (RBA) of the life-sustaining medical procedures addressed on standardized forms. The current article describes a new patient-centered nurse-supported advance care planning (NSACP) intervention focused on providing information about RBA of life-sustaining procedures. Fifty participants (mean age = 50.26 years) at a Veterans Affairs medical center were randomized to the NSACP intervention or a comparison condition. Before randomization, 78% (n = 39) expressed interest in RBA information. Of participants in the NSACP group, 94% (n = 30) completed an AD. Participants who received NSACP made more decisions to decline life-sustaining treatment than those who were randomized to the comparison group. Promising feasibility data include brevity (mean = 46 minutes), high patient satisfaction, participant retention, and treatment fidelity. The NSACP holds promise as a brief, educational intervention to support patients in completing an AD. [Journal of Gerontological Nursing, 44(7), 31-42.].

Happy Despite Pain: A Randomized Controlled Trial of an 8-Week Internet-delivered Positive Psychology Intervention for Enhancing Well-being in Patients With Chronic Pain

Supplemental Digital Content is available in the text.

Objectives:

There is preliminary evidence for the efficacy of positive psychology interventions for pain management. The current study examined the effects of an internet-based positive psychology self-help program for patients with chronic musculoskeletal pain and compared it with an internet-based cognitive-behavioral program.

Materials and Methods:

A randomized controlled trial was carried out with 3 conditions: an internet-delivered positive psychology program, an internet-delivered cognitive-behavioral program and waitlist control. A total of 276 patients were randomized to 1 of the 3 conditions and posttreatment data were obtained from 206 patients. Primary outcomes were happiness, depression, and physical impairments at posttreatment and at 6-month follow-up. Intention-to-treat analyses were carried out using mixed regression analyses.

Results:

Both treatments led to significant increases in happiness and decreases in depression. Physical impairments did not significantly decrease compared with waitlist. Improvements in happiness and depression were maintained until 6-month follow-up. There were no overall differences in the efficacy of the 2 active interventions but effects seemed to be moderated by education. Patients with a higher level of education profited slightly more from the positive psychology intervention than from the cognitive-behavioral program.

Discussion:

The results suggest that an internet-based positive psychology and cognitive-behavioral self-help interventions for the management of chronic pain are clinically useful. Because the self-help exercises as used in the current program do not require therapist involvement, dissemination potential is large. Further studies should examine whether it can best be used as stand-alone or add-on treatment combined with established pain treatment programs.

Evaluation of the analgesic and pharmacokinetic properties of transdermally administered fentanyl in goats

OBJECTIVE

Evaluate the analgesic properties and pharmacokinetics of transdermal fentanyl patches (TFPs) in goats.

DESIGN

Prospective, randomized study.

SETTING

Preclinical Testing Facility at a University Teaching Hospital.

ANIMALS

Thirty-four adult female Boer-cross goats.

INTERVENTIONS

Goats underwent surgery as part of a concurrent orthopedic research study. Twelve hours prior to surgery, each goat received a TFP (target dosage of 2.5 μg/kg/h), or a placebo patch with analgesia provided by buprenorphine (0.01 mg/kg, IM, q 6 h). Patches were removed after 72 hours. Blood was sampled at specified intervals, up to 84 hours following TFP placement. Plasma concentrations of fentanyl (FEN) were determined using liquid chromatography-mass spectrometry. Postoperative pain assessments were performed by two independent blinded observers.

MEASUREMENTS AND MAIN RESULTS

TFPs were applied at a mean (± standard deviation, SD) dose of 2.54 ± 0.36 μg/kg/h. No adverse events occurred. Pain scores between TFP and BUP groups were not significantly different at any time point. Mean plasma FEN concentration (± SD) 2 hours following patch application was 1.06 ± 0.85 ng/mL, and remained above 0.5 ng/mL for 40 hours. Maximum mean plasma FEN concentration (C_max ) was 1.84 (ranging from 0.81 to 3.35) ng/mL with average time to maximum concentration (T_max ) of 12 hours after patch application.

CONCLUSIONS

TFP resulted in consistent FEN absorption and plasma concentrations within the human and ovine therapeutic ranges. Pain scores for goats administered TFP were not different than those administered buprenorphine. Ease of administration, duration of analgesia, and decreased dosing frequency make TFPs an attractive option for pain management in goats.

Antibiotics for performing voiding cystourethrogram: a randomised control trial

OBJECTIVE

To assess whether antibiotic reduces voiding cystourethrogram (VCUG)-associated urinary tract infection (UTI).

DESIGN

Open-labelled randomised controlled trial.

SETTING

Tertiary paediatric nephrology centre.

PATIENTS

120 children (age 2 months-5 years) undergoing VCUG.

INTERVENTIONS

Children were randomised into group A (antibiotic, n=72) or group B (no antibiotic, n=48) in 3:2 ratio. Group A received oral antibiotic (cephalexin if <6 months or co-trimoxazole if >6 months old) a day prior to VCUG and continued for 1 day post VCUG.

MAIN OUTCOME MEASURES

The main outcome measure is incidence of VCUG-associated UTI. Urine was checked on day 3 after VCUG and UTI was defined as significant growth of a single organism in a symptomatic child.

RESULTS

The median age was 8 months (IQR 13 months) with 68% male. Indication for undertaking VCUG was history of UTI (first UTI in infancy=43, recurrent UTI=49) and congenital anomaly of kidney and urinary tract without any UTI (n=28). Post-VCUG UTI was significantly higher among group B in comparison to group A (17% (n=8) vs 1.4% (n=1); p=0.01, OR=14.2 (95% CI 1.7 to 117)). Multivariate binary logistic regression analysis found an abnormal pre-VCUG ultrasound scan to be a significant independent risk factor for post-VCUG UTI (p=0.02, OR=9.51, 95% CI 1.43 to 63.4). The number needed to treat with antibiotic to prevent one post-VCUG UTI was 6.5, which reduced to 4 if only the group with abnormal pre-VCUG ultrasound scan was included.

CONCLUSIONS

Antibiotic significantly reduces post-VCUG-acquired UTI especially in those with abnormal ultrasound scans.

TRIAL REGISTRATION NUMBER

Clinical Trial Registry of India: CTRI/2017/03/00824.