CONSORT 2010 statement: extension to randomised crossover trials

Accompanied versus unaccompanied walking for continuous oxygen saturation measurement during 6-min walk test in COPD: a randomised crossover study

The aim of this study was to determine if there is a difference in 6-min walk test (6MWT) distance when the assessor accompanies the patient to continuously measure peripheral oxygen saturation (S_pO2) compared to the patient walking unaccompanied.

 We conducted a randomised crossover study to evaluate the impact of the assessor walking with the patient during the 6MWT (6MWT_with) versus the patient walking alone (6MWT_without). At the end of a pulmonary rehabilitation programme, each patient performed two 6MWTs in random order and separated by a 30-min rest.

 49 patients with chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease classification II–IV) were included. In a regression model adjusting for period and subject, accompanying the patient resulted in a lower walking distance (mean difference −9.1 m, 95% CI −13.9– −4.3, p=0.0004). Notably, six patients walked more than 30 m farther (minimal important difference) in one of the two conditions (6MWT_with: n=1, 6MWT_without: n=5). There were no between-sequence-group differences in heart rate, dyspnoea, leg fatigue and S_pO2. The median (interquartile range) number and duration of S_pO2 signal artefacts were high but not different between the experimental conditions (6MWT_with: 17 (4–24), 34 s (7–113 s); 6 MWT_without: 11 (3–26), 24 s (4–62 s)).

 At a study population level, we observed a statistically significant difference in 6MWT distance between the two experimental conditions; however, the magnitude of difference was small and may not be clinically relevant. Nevertheless, in a clinical setting, unaccompanied walking resulted in a substantially higher walking distance in individual patients, pointing towards strictly standardised testing methodology, in particular in pre–post study designs.

Accompanied walking during a 6MWT versus unaccompanied walking results in shorter walked distance (mean difference −9.1 m, 95% CI −13.9– −4.3 m). No differences in nadir S_pO2 or oximetry artefacts were noted between accompanied and unaccompanied walking.https://bit.ly/3tBjfCq

Effect of Wholegrain Flour Particle Size in Bread on Glycaemic and Insulinaemic Response among People with Risk Factors for Type 2 Diabetes: A Randomised Crossover Trial

Wholegrain flour produced by roller-milling is predominantly comprised of fine particles, while stoneground flour tends to have a comparatively smaller proportion of fine particles. Differences in flour particle size distribution can affect postprandial glycaemia in people with type 2 diabetes and postprandial insulinaemia in people with and without type 2 diabetes. No prior studies have investigated the effect of wholegrain flour particle size distribution on glycaemic or insulinaemic response among people with impaired glucose tolerance or risk factors for type 2 diabetes. In a randomised crossover study, we tested the 180-min acute glycaemic and insulinaemic responses to three wholegrain breads differing in flour particle size and milling method: (1) fine roller-milled flour, (2) fine stoneground flour, and (3) coarse stoneground flour. Participants (n = 23) were males and females with risk factors for type 2 diabetes (age 55-75 y, BMI >28 kg/m², completing less than 150 min moderate to vigorous intensity activity per week). Each test meal provided 50 g available carbohydrate, and test foods were matched for energy and macronutrients. There was no significant difference in blood glucose iAUC (incremental area under the curve) between the coarse stoneground flour bread and the fine stoneground flour bread (mean difference -20.8 (95% CI: -51.5, 10.0) mmol·min/L) and between the coarse stoneground flour bread and the fine roller-milled flour bread (mean difference -23.3 (95% CI: -57.6, 11.0) mmol·min/L). The mean difference in insulin iAUC for fine stoneground flour bread compared with the fine roller-milled flour bread was -6.9% (95% CI: -20.5%, 9.2%) and compared with the coarse stoneground flour bread was 9.9% (95% CI: -2.6%, 23.9%). There was no evidence of an effect of flour particle size on postprandial glycaemia and insulinaemia among older people with risk factors for type 2 diabetes, most of whom were normoglycaemic.

Combining transcranial magnetic stimulation with functional magnetic resonance imaging for probing and modulating neural circuits relevant to affective disorders

Combining transcranial magnetic stimulation (TMS) with functional magnetic resonance imaging offers an unprecedented tool for studying how brain networks interact in vivo and how repetitive trains of TMS modulate those networks among patients diagnosed with affective disorders. TMS compliments neuroimaging by allowing the interrogation of causal control among brain circuits. Together with TMS, neuroimaging can provide valuable insight into the mechanisms underlying treatment effects and downstream circuit communication. Here we provide a background of the method, review relevant study designs, consider methodological and equipment options, and provide statistical recommendations. We conclude by describing emerging approaches that will extend these tools into exciting new applications. This article is categorized under: Psychology > Emotion and Motivation Psychology > Theory and Methods Neuroscience > Clinical Neuroscience.

An integrated program of computer-presented and physical cognitive training exercises for children with attention-deficit/hyperactivity disorder

BACKGROUND

This study integrated an experimental medicine approach and a randomized cross-over clinical trial design following CONSORT recommendations to evaluate a cognitive training (CT) intervention for attention deficit hyperactivity disorder (ADHD). The experimental medicine approach was adopted because of documented pathophysiological heterogeneity within the diagnosis of ADHD. The cross-over design was adopted to provide the intervention for all participants and make maximum use of data.

METHODS

Children (n = 93, mean age 7.3 +/- 1.1 years) with or sub-threshold for ADHD were randomly assigned to CT exercises over 15 weeks, before or after 15 weeks of treatment-as-usual (TAU). Fifteen dropped out of the CT/TAU group and 12 out of the TAU/CT group, leaving 66 for cross-over analysis. Seven in the CT/TAU group completed CT before dropping out making 73 available for experimental medicine analyses. Attention, response inhibition, and working memory were assessed before and after CT and TAU.

RESULTS

Children were more likely to improve with CT than TAU (27/66 v. 13/66, McNemar p = 0.02). Consistent with the experimental medicine hypotheses, responders improved on all tests of executive function (p = 0.009-0.01) while non-responders improved on none (p = 0.27-0.81). The degree of clinical improvement was predicted by baseline and change scores in focused attention and working memory (p = 0.008). The response rate was higher in inattentive and combined subtypes than hyperactive-impulsive subtype (p = 0.003).

CONCLUSIONS

Targeting cognitive dysfunction decreases clinical symptoms in proportion to improvement in cognition. Inattentive and combined subtypes were more likely to respond, consistent with targeted pathology and clinically relevant heterogeneity within ADHD.

Acute effects of dapagliflozin on renal oxygenation and perfusion in type 1 diabetes with albuminuria: A randomised, double-blind, placebo-controlled crossover trial

BACKGROUND

Inhibitors of the sodium-glucose cotransporter 2 (SGLT2) slow the progression of diabetic kidney disease, possibly by reducing the proximal tubule transport workload with subsequent improvement of renal oxygenation. We aimed to test this hypothesis in individuals with type 1 diabetes and albuminuria.

METHODS

A randomised, double-blind, placebo-controlled, crossover trial with a single 50 mg dose of the SGLT2 inhibitor dapagliflozin and placebo in random order, separated by a two-week washout period. Magnetic resonance imaging (MRI) was used to assess renal R2* (a low value corresponds to a high tissue oxygenation), renal perfusion (arterial spin labelling) and renal artery flow (phase contrast imaging) at baseline, three- and six hours from tablet ingestion. Exploratory outcomes, including baroreflex sensitivity, peripheral blood oxygen saturation, peripheral blood mononuclear cell mitochondrial oxygen consumption rate, and biomarkers of inflammation were evaluated at baseline and 12 h from medication. The study is registered in the EU Clinical Trials Register (EudraCT 2019-004,557-92), on ClinicalTrials.gov (NCT04193566), and is completed.

FINDINGS

Between February 3, 2020 and October 23, 2020, 31 individuals were screened, and 19 eligible individuals were randomised. Three dropped out before receiving any of the interventions and one dropped out after receiving only placebo. We included 15 individuals (33% female) in the per-protocol analysis with a mean age of 58 (SD 14) years, median urinary albumin creatinine ratio of 46 [IQR 21-58] mg/g and an eGFR of 73 (32) ml/min/1·73m2. The mean changes in renal cortical R2* from baseline to six hours were for dapagliflozin -1·1 (SD 0·7) s-1 and for placebo +1·3 (0·7) s-1, resulting in a difference between interventions of -2·3 s-1 [95% CI -4·0 to -0·6]; p = 0·012. No between-intervention differences were found in any other MRI outcomes, physiological parameters or exploratory outcomes. There were no adverse events.

INTERPRETATION

A single dose of 50 mg dapagliflozin acutely improved renal cortical R2* without changing renal perfusion or blood flow. This suggests improved renal cortical oxygenation due to a reduced tubular transport workload in the proximal tubules. Such improved oxygenation may in part explain the long-term beneficial renal effects seen with SGLT2 inhibitors, but it remains to be determined whether the observed effects can be achieved with lower doses, with chronic treatment and if they occur in type 2 diabetes as well.

Quality of reporting of clinical trials in dogs and cats: An update

BACKGROUND

Comprehensive reporting of clinical trials is essential to allow the trial reader to evaluate the methodological rigor of the trial and interpret the results. Since publication of the updated Consolidated Standards of Reporting Trials (CONSORT) guidelines for reporting of parallel clinical trials in humans, extensions for reporting of abstracts and crossover trials have been published.

OBJECTIVES

To describe the types of trials using dogs and cats published from 2015 to 2020 and to evaluate the quality of reporting of a sample of recently published parallel and crossover trials.

ANIMALS

None.

METHODS

A comprehensive search was conducted to identify parallel or crossover design clinical trials using dogs and cats published from January 1, 2015 onwards. Quality of reporting was evaluated on a subset of trials published during 2019. The reporting of items recommended in the CONSORT reporting guidelines for abstracts, parallel trials, and crossover trials was evaluated independently by 2 reviewers using standardized forms created for this study. Disagreements among reviewers were resolved by consensus. Results were tabulated descriptively.

RESULTS

The frequency of reporting of trial features varied from low to high. There remain deficiencies in the quality of reporting of key methodological features and information needed to evaluate and interpret trial results.

CONCLUSIONS AND CLINICAL IMPORTANCE

There is still a need for authors, peer-reviewers, and editors to follow reporting guidelines such as CONSORT to maximize the value of clinical trials and to increase confidence in the validity of the trial results.

Using a novel smartphone application for capturing of patient-reported outcome measures among patients with inflammatory arthritis:A randomized, crossover, agreement study

Objectives: In Denmark, patients with inflammatory arthritis (IA) have completed patient-reported outcome measures (PROMs) via touchscreens in the outpatient clinic since 2006. However, current technology makes it possible for patients to use their own smartphone via an application (app) developed for the Danish Rheumatology Database (DANBIO). This study aims to evaluate the agreement of PROMs between the DANBIO app and outpatient touchscreen in patients with IA.Method: Patients with IA (rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis) were enrolled in a randomized, crossover, agreement study. Participants answered PROMs through the two device types in a randomized order. Differences in PROM scores with 95% confidence intervals (CIs) were evaluated for similarity according to prespecified equivalence margins.Results: The touchscreen invitation was accepted by 138 patients. Sixty patients (20 with each diagnosis) were included. The difference in Health Assessment Questionnaire Disability Index between the two device types was -0.007 (95% CI -0.043 to 0.030); thus, equivalence was demonstrated. In addition, all other PROMs obtained with the two device types were equivalent, except for the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), which was within the limits of minimally clinically important difference (MCID). In total, 78.3% preferred the DANBIO app.Conclusion: In patients with IA, equivalence was demonstrated between two device types for all PROMs except BASDAI; however, BASDAI was within the limits of the MCID. Implementation of the DANBIO app is expected to optimize outpatient visits, thereby improving healthcare for the individual patient and society.

Alternating Current Is More Fatigable Than Pulsed Current in People Who Are Healthy: A Double-Blind, Randomized Crossover Trial

OBJECTIVE

Tolerance level and rapid fatigue onset are limitations in the use of neuromuscular electrical stimulation (NMES) as an electrotherapeutic resource in rehabilitation and training protocols; however, it is unclear if pulsed current (PC) and alternating current (AC) produce different fatigue levels when applied at submaximal contraction level. The purpose of this study was to compare fatigue and discomfort levels between PC and AC during a submaximal contraction protocol in people who are healthy.

METHODS

In this double-blind, randomized crossover trial conducted in a laboratory setting, 30 male volunteers [23.23 years of age (SD = 4.59)] performed 2 submaximal fatigue protocols (with a 7-day interval) in a randomized order: PC (pulse duration = 2 milliseconds, pulse frequency = 100 Hz) and AC (2.5 kHz, pulse duration = 0.4 milliseconds, burst frequency = 100 Hz). NMES currents were applied to the knee extensor motor point of the dominant limb. The NMES protocol consisted of 80 evoked contractions (time on:off = 5:10 seconds) and lasted 20 minutes. The current was maintained at a constant intensity throughout the NMES protocol. The primary outcome measures were maximal voluntary isometric contraction, fatigue index (evoked torque decline), fatigability (number of contractions for a 50% drop in evoked-torque from the protocol start), total evoked torque-time integral (TTI), decline in TTI, and discomfort level.

RESULTS

AC at 2.5 kHz demonstrated higher maximal voluntary isometric contraction decline post-fatigue, higher fatigue index, higher fatigability (ie, fewer contractions to reach the 50% evoked torque decline from the protocol start), smaller total TTI, and higher TTI decline compared with PC. No between-currents difference was observed in discomfort level.

CONCLUSION

PC is less fatigable than AC at 2.5 kHz.

IMPACT

Based on this study, PC is the preferred current choice when the NMES goal is to generate higher muscle work, higher mechanical load, and smaller fatigability during training both for athletes who are healthy and for rehabilitation programs for people with disease or injury.

Effects of a whey protein pre-meal on bone turnover in participants with and without type 2 diabetes-A post hoc analysis of a randomised, controlled, crossover trial

AIMS

Whey protein may improve bone turnover and have anti-osteoporotic effects. The aim of the present randomised, controlled, crossover trial was to evaluate the effects of a whey protein pre-meal on bone turnover in people with type 2 diabetes and controls.

METHODS

Two groups, matched on sex, age and body mass index, comprising 12 participants with and 12 participants without type 2 diabetes were randomly given a pre-meal of whey protein (20 g) or water, which was consumed 15 min before a fat-rich meal or a fat-rich meal supplemented with 20 g whey protein. During a 360-min period, postprandial responses in bone turnover were examined.

RESULTS

Osteocalcin, P-procollagen type 1 amino terminal propeptide (P1NP), C-terminal cross-linked telopeptide of type-I collagen (CTX) and parathyroid hormone (PTH) were lower at baseline and PTH, osteocalcin and P1NP were lower during the entire postprandial phase in participants with type 2 diabetes than in participants without type 2 diabetes. We observed similar postprandial responses in bone turnover markers between persons with and without type 2 diabetes. We observed no effect of the whey protein or the water pre-meal on bone turnover markers. The changes were unrelated to secretion of hormones of the gut-bone axis.

CONCLUSION

Osteocalcin, P1NP, CTX and PTH all decreased following meal ingestion. We observed no convincing effect of a whey protein pre-meal on bone turnover. However, these results confirm that people with type 2 diabetes have low bone turnover and that the decreased bone formation markers are also extend into the postprandial responses.

Interacting with virtual objects via embodied avatar hands reduces pain intensity and diverts attention

The current study introduces a new paradigm for exploring cognitive factors in pain. Interacting with virtual objects via embodied avatar hands increased the illusion of “being there” in the virtual world, increased VR analgesia for acute pain, and reduced accuracy on an attention demanding task. Twenty-four healthy volunteer college students participated in this within-subject randomized crossover design study. During Phase 1, each participant received brief thermal pain stimuli during interactive embodied avatar VR vs. passive VR (no avatar and no interactivity), VR treatment order randomized. After each pain stimulus, participants provided subjective 0–10 ratings of pain. Compared to the passive VR condition, during the interactive avatar VR, participants reported significant reductions in (1) worst pain, (2) pain unpleasantness, (3) time thinking about pain and (4). they had significantly more fun during the pain stimulus (p = .000 for each). During Phase 2, participants performed a divided attention task in each of the two VR conditions. Participants made significantly more errors on the divided attention task during the interactive avatar VR condition, compared to passive VR, implicating an attention mechanism for how virtual reality reduces pain and helping understand how VR influences pain perception.

Trial registration: NCT04245475. Date of registration: 29/01/2020.

Vagal reactivation after a cardiac rehabilitation session associated with hydration in coronary artery disease patients: crossover clinical trial

This study aimed to investigate the hydration influence on the autonomic responses of coronary artery disease subjects in the immediate recovery period after a cardiovascular rehabilitation session, in view of the risks of a delayed autonomic recovery for this population. 28 males with coronary artery disease were submitted to: (I) Maximum effort test; (II) Control protocol (CP), composed by initial rest, warm-up, exercise and passive recovery; (III) Hydration protocol (HP) similar to CP, but with rehydration during exercise. The recovery was evaluated through the heart rate (HR) variability, HR recovery and by the rate of perceived exertion and recovery. The main results revealed that the vagal reactivation occurred at the first 30 s of recovery in HP and after the first minute in CP. A better behavior of the HR at the first minute of recovery was observed in HP. The rate of perceived exertion had a significant decrease in the first minute of recovery in HP, while in CP this occurred after the third minute. In conclusion, despite an anticipated vagal reactivation found at HP, these results should be analyzed with caution as there were no significant differences between protocols for all variables and the effect sizes were small.

Perspective: Planning and Conducting Statistical Analyses for Human Nutrition Randomized Controlled Trials: Ensuring Data Quality and Integrity

Appropriate planning, execution, and reporting of statistical methods and results is critical for research transparency, validity, and reproducibility. This paper provides an overview of best practices for developing a statistical analysis plan a priori, conducting statistical analyses, and reporting statistical methods and results for human nutrition randomized controlled trials (RCTs). Readers are referred to the other NURISH (NUtrition inteRventIon reSearcH) publications for detailed information about the preparation and conduct of human nutrition RCTs. Collectively, the NURISH series outlines best practices for conducting human nutrition research.

Evaluation of students' performance and engagement using post-laboratory integrated assessments within a pharmacy course in the United Kingdom: a pilot cohort cross-over study

INTRODUCTION

This pilot study investigated the impact of practice integrated, post-laboratory assessment on the scientific education and attitudes of first-year pharmacy students. Median assessment performance, achievement of full marks, and engagement in laboratory classes were evaluated.

METHODS

The pilot randomised cross-over study was conducted at the University of Central Lancashire. Students were randomly assigned to two groups, and after undertaking four identical pharmaceutics laboratory classes, answered two science-based questions that were either integrated with practice using a contextualizing scenario or had no integration. Student performance and engagement were subsequently analysed.

RESULTS

Thirty students completed the study. Students performed better in the integrated assessment (median 3.5; interquartile range [IQR] 2.00-4.00) compared to the non-integrated assessment (median 2; IQR 1.75-3.00) (P < .001). Twenty-five students (83%) achieved full marks with the integrated assessment (P = .006). Correlation (R²) for the integrated assessment was 0.90 and for the non-integrated assessment was 0.12. Engagement was positive in both groups but significantly improved in the domains of "instructor contribution" and "value of activity" (P = .01) when receiving the integrated assessment.

CONCLUSIONS

Integrated and contextualized assessment of science teaching as a lone intervention increased pharmacy students' performance and engagement in laboratory classes without requiring any change to the teaching session itself.

Effect and usability of anti-inflammatory drug plasters for knee osteoarthritis: A crossover, double-blind, repeated measures, randomized controlled trial

BACKGROUND

The use of plasters is a well-accepted treatment with high adherence. However, the characteristics such as its cool feeling or extensibility favored by elderly have a possibility to contribute to clinical utility. The purpose is to examine the effect of anti-inflammatory drug plasters for knee osteoarthritis and the clinical preference of the patients for using plasters. We conducted a crossover, double-blind, randomized controlled trial (RCT) recruited 168 patients with knee osteoarthritis.

METHODS

We included a "run-in-period" to evaluate the patients' preference among A (first-generation; methyl salicylate), B (second-generation; indomethacin), and N (base substrate for B) before the crossover sequence of two treatment periods with A and B plasters; four arms (N-A-B, A-A-B, N-B-A, and B-B-A) were made to compare the assessment of A, B, and N plasters. We used two measures: The Japanese Knee Osteoarthritis Measure (JKOM), for clinical functions, and the usability questionnaire to evaluate the clinical value of plasters.

RESULTS

At baseline, there were no significant differences in characteristics. The subjects in groups A and B showed improved overall JKOM scores at the end of each intervention. Comparison of the change of the mean difference showed that A and B were statistically significant improvement over N (-2.40, (95%CI = -3.58 to -1.21), -2.52, (-3.65 to -1.40)) but no significant difference between A and B - 0.13, (-1.14 to 0.89)). In network analysis for usability, twelve items were independent of JKOM's network structure and consisted of two domains. The analysis of usability showed that N and B were preferred over A significantly.

CONCLUSION

Both the first- and second-generation plasters were statistically superior to the base only, but no significant difference between two generations. The patient is surely aware of the effect of the drug itself, but the two feelings are important in the preference.

The effects of barbell resistance exercise on information processing speed and conflict-related ERP in older adults: a crossover randomized controlled trial

It is difficult to draw conclusions about the effect of resistance exercises on information processing speed and inhibitory control from previous studies due to possible underestimations of maximal strength and the lack of information on the intervention programs. To address this issue, a familiarization of resistance exercise was introduced before the strength test, and the repetition-to-fatigue method was used to calculate the 1RM (one repetition max). A two-arm RCT was conducted to evaluate the cognitive effect of resistance exercise. Male adults aged 50-65 years old performed a single bout of multiple joint, structural barbell resistance exercises (back squat, press, and deadlift) with 75% 1RM * 5 repetitions * 3 sets with 2-3 min rest between sets and exercises or a stretching exercise session (active-control intervention). This type of resistance exercise improved the information processing speed measured by Stroop task reaction time (t(23) =  - 2.313, p = .030, M =  - 16 ms, 95% CI [- 30, - 2]) and decreased the conflict-related neural activity measured by event-related potential N2b in both congruent (t(20) = 2.674, p = .015, M = 2.290 μv, 95% CI [0.504, 4.075]) and incongruent (t(20) = 2.851, p = .018, M = 2.291 μv, 95% CI [0.439, 4.142]) conditions. Resistance exercise significantly improved information processing speed and decrease conflict-related neural activity, but did not change inhibitory control in older adults compared to active control.Trial registration: NCT04534374 (01/09/2020).

Thalamic Deep Brain Stimulation for Spasmodic Dysphonia: A Phase I Prospective Randomized Double-Blind Crossover Trial

BACKGROUND

Adductor spasmodic dysphonia (SD) is a dystonia of the vocal folds causing difficulty with speech. The current standard of care is repeated botulinum toxin injections to weaken the adductor muscles. We sought to ameliorate the underlying neurological cause of SD with a novel therapy—deep brain stimulation (DBS).

OBJECTIVE

To assess the safety of DBS in SD through phase I trial, and to quantify the magnitude of any benefit.

METHODS

Six patients had left ventral intermediate nucleus (Vim) thalamic DBS and were randomized to 3 mo blinded-DBS “on” or “off” followed by a crossover. Primary outcomes were quality of life and quality of voice during the blinded phase. Patients continued with open-DBS “on.” Secondary outcomes were comparisons of pre- and 1-yr cognitive, mood, and quality of life. This trial was registered with ClinicalTrials.gov (NCT02558634).

RESULTS

There were no complications. Every patient reported an improvement in quality of life (P = .07) and had an improvement in quality of their voice (P = .06) when their blinded DBS was “on” versus “off.” The trend did not reach statistical significance with the small sample size. Secondary outcomes showed no difference in cognition, an improvement in mood, and quality of life at 1 yr.

CONCLUSION

This phase I randomized controlled trial confirmed that DBS can be performed safely in patients with SD. Blinded DBS produced a strong trend toward improved quality of life and objective quality of voice despite the small sample size. The cerebellar circuit, not the pallidal circuit, appears to be crucial for motor control of the vocal folds.

Effects of 5-aminolevulinic acid with iron supplementation on respiratory responses to graded cycling and interval walking training achievement in older women over 75 yrs

BACKGROUND

Exercise training above a given intensity is necessary to prevent age-associated physical disability and diseases; however, the physical and psychological barriers posed by deteriorated physical fitness due to aging may hinder older people from performing daily exercise training. Because 5-aminolevulinic acid (ALA), a precursor of heme, reportedly improves mitochondrial function, we examined whether ALA, combined with sodium ferrous citrate (SFC) for enhancement, improved aerobic capacity and voluntary exercise training achievement in older women aged over 75 yrs.

METHODS

The study was conducted using a placebo-controlled, double-blind crossover design. Fifteen women aged ~78 yrs. with no exercise habits underwent two trials for 7 days each where they performed interval walking training (IWT), repeating fast and slow speeds of walking for 3 min each, at >70% and at ~40% of peak aerobic capacity for walking, respectively, with ALA+SFC (100 and 115 mg/day, respectively) or placebo supplement intake (CNT), with a 12-day washout period. Before and after each trial, subjects underwent a graded cycling test while having their oxygen consumption rate (V·O₂), carbon dioxide production rate (V·CO₂), and plasma lactate concentration ([Lac^-]_p) measured. Furthermore, during the supplement intake period, exercise intensity for IWT was measured by accelerometry.

RESULTS

In ALA+SFC, the increases in V·O₂ and V·CO₂ during the graded cycling test were attenuated (both, P < 0.01) with a 13% reduction in [Lac^-]_p (P = 0.012) while none of these attenuated responses occurred in CNT (all, P > 0.46). Furthermore, energy expenditure and time during fast walking for IWT were 25% (P = 0.032) and 21% (P = 0.022) higher in ALA+SFC than in CNT.

CONCLUSION

Thus, ALA+SFC supplementation improved aerobic capacity and thus increased fast-walking training achievement in older women.

Hemodynamic Response to High- and Low-Load Resistance Exercise in Patients with Coronary Artery Disease: A Randomized, Crossover Clinical Trial

Low-load resistance exercise (LL-RE) is recommended as an adjunct therapy to aerobic exercise during cardiac rehabilitation in patients with coronary artery disease. The safety and hemodynamic response to high-load (HL) RE remain unknown. The aim of this study was to evaluate the hemodynamic response during both HL-RE and LL-RE prior to cardiac rehabilitation. Forty-three patients with coronary artery disease and/or percutaneous coronary intervention performed three sets of leg-press exercise using HL-RE (eight repetitions at the intensity of 80% of one repetition maximum (1-RM)) and LL-RE (16 repetitions at the intensity of 40% 1-RM) in a randomized crossover sequence. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and rating of perceived exertion were measured at baseline, after each set of RE and post-exercise. No clinically relevant changes in HR and BP or in patient-reported symptoms were recorded during HL-RE or LL-RE. Compared with baseline, HR and SBP increased during LL-RE (from 66 bpm to 86 bpm, time effect: p < 0.001; from 129 mmHg to 146 mmHg, time effect: p < 0.001) and HL-RE (from 68 bpm to 86 bpm, time effect: p < 0.001; from 130 mmHg to 146 mmHg, time effect: p < 0.001). Compared with HL-RE, the increase in HR was greater after the final set of LL-RE (32% vs. 28%, p = 0.015), without significant differences in SBP and DBP between LL-RE and HL-RE. Rating of perceived exertion was higher after the 1st set of HL-RE compared with LL-RE (median (interquartile range): 6 (5–7) vs. 6 (5–6), p = 0.010). In patients with coronary artery disease, both HL-RE and LL-RE were safe and well-tolerated. Hemodynamic changes were similar and within the physiological response to RE.

Changes in lipoprotein particle subclasses, standard lipids, and apolipoproteins after supplementation with n-3 or n-6 PUFAs in abdominal obesity: A randomized double-blind crossover study

BACKGROUND & AIMS

Marine-derived omega-3 (n-3) polyunsaturated fatty acids (PUFAs), mainly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), lower circulating levels of triacylglycerols (TAGs), and the plant-derived omega-6 (n-6) PUFA linoleic acid (LA) may reduce cholesterol levels. Clinical studies on effects of these dietary or supplemental PUFAs on other blood fat fractions are few and have shown conflicting results. This study aimed to determine effects of high-dose supplemental n-3 (EPA + DHA) and n-6 (LA) PUFAs from high-quality oils on circulating lipoprotein subfractions and standard lipids (primary outcomes), as well as apolipoproteins, fatty acids, and glycemic control (secondary outcomes), in females and males with abdominal obesity.

METHODS

This was a randomized double-blind crossover study with two 7-wk intervention periods separated by a 9-wk washout phase. Females (n = 16) were supplemented with 3 g/d of EPA + DHA (TAG fish oil) or 15 g/d of LA (safflower oil), while males (n = 23) received a dose of 4 g/d of EPA + DHA or 20 g/d of LA. In fasting blood samples, we investigated lipoprotein particle subclasses by nuclear magnetic resonance spectroscopy, as well as standard lipids, apolipoproteins, fatty acid profiles, and glucose and insulin. Data were analyzed by linear mixed-effects modeling with 'subjects' as the random factor.

RESULTS

The difference between interventions in relative change scores was among the lipoprotein subfractions significant for total very-low-density lipoproteins (VLDLs) (n-3 vs. n-6: -38%∗ vs. +16%, p < 0.001; ∗: significant within-treatment change score), large VLDLs (-58%∗ vs. -0.91%, p < 0.001), small VLDLs (-57%∗ vs. +41%∗, p < 0.001), total low-density lipoproteins (LDLs) (+5.8%∗ vs. -4.3%∗, p = 0.002), large LDLs (+23%∗ vs. -2.1%, p = 0.004), total high-density lipoproteins (HDLs) (-6.0%∗ vs. +3.7%, p < 0.001), large HDLs (+11%∗ vs. -5.3%, p = 0.001), medium HDLs (-24%∗ vs. +6.2%, p = 0.030), and small HDLs (-9.9%∗ vs. +9.6%∗, p = 0.002), and among standard lipids for TAGs (-16%∗ vs. -2.6%, p = 0.014), non-esterified fatty acids (-19%∗ vs. +5.5%, p = 0.033), and total cholesterol (-0.28% vs. -4.4%∗, p = 0.042). A differential response in relative change scores was also found for apolipoprotein (apo)B (+0.40% vs. -6.0%∗, p = 0.008), apoA-II (-6.0%∗ vs. +1.5%, p = 0.001), apoC-II (-11%∗ vs. -1.7%, p = 0.025), and apoE (+3.3% vs. -3.8%, p = 0.028).

CONCLUSIONS

High-dose supplementation of high-quality oils with n-3 (EPA + DHA) or n-6 (LA) PUFAs was followed by reductions in primarily TAG- or cholesterol-related markers, respectively. The responses after both interventions point to changes in the lipoprotein-lipid-apolipoprotein profile that have been associated with reduced cardiometabolic risk, also among people with TAG or LDL-C levels within the normal range.

REGISTRATION

Registered under ClinicalTrials.gov Identifier: NCT02647333.

CLINICAL TRIAL REGISTRATION

Registered at https://clinicaltrials.gov/ct2/show/NCT02647333.

Effects of Hospital-Based Comprehensive Medication Reviews Including Postdischarge Follow-up on Older Patients' Use of Health Care: A Cluster Randomized Clinical Trial

Importance

Suboptimal use of medications is a leading cause of health care-related harm. Medication reviews improve medication use, but evidence of the possible benefit of inpatient medication review for hard clinical outcomes after discharge is scarce.

Objective

To study the effects of hospital-based comprehensive medication reviews (CMRs), including postdischarge follow-up of older patients' use of health care resources, compared with only hospital-based reviews and usual care.

Design, Setting, and Participants

The Medication Reviews Bridging Healthcare trial is a cluster randomized crossover trial that was conducted in 8 wards with multiprofessional teams at 4 hospitals in Sweden from February 6, 2017, to October 19, 2018, with 12 months of follow-up completed December 6, 2019. The study was prespecified in the trial protocol. Outcome assessors were blinded to treatment allocation. In total, 2644 patients aged 65 years or older who had been admitted to 1 of the study wards for at least 1 day were included. Data from the modified intention-to-treat population were analyzed from December 10, 2019, to September 9, 2020.

Interventions

Each ward participated in the trial for 6 consecutive 8-week periods. The wards were randomized to provide 1 of 3 treatments during each period: CMR, CMR plus postdischarge follow-up, and usual care without a clinical pharmacist.

Main Outcomes and Measures

The primary outcome measure was the incidence of unplanned hospital visits (admissions plus emergency department visits) within 12 months. Secondary outcomes included medication-related admissions, visits with primary care clinicians, time to first unplanned hospital visit, mortality, and costs of hospital-based care.

Results

Of the 2644 participants, 7 withdrew after inclusion, leaving 2637 for analysis (1357 female [51.5%]; median age, 81 [interquartile range, 74-87] years; median number of medications, 9 [interquartile range, 5-13]). In the modified intention-to-treat analysis, 922 patients received CMR, 823 received CMR plus postdischarge follow-up, and 892 received usual care. The crude incidence rate of unplanned hospital visits was 1.77 per patient-year in the total study population. The primary outcome did not differ between the intervention groups and usual care (adjusted rate ratio, 1.04 [95% CI, 0.89-1.22] for CMR and 1.15 [95% CI, 0.98-1.34] for CMR plus postdischarge follow-up). However, CMR plus postdischarge follow-up was associated with an increased incidence of emergency department visits within 12 months (adjusted rate ratio, 1.29; 95% CI, 1.05-1.59) compared with usual care. There were no differences between treatment groups regarding other secondary outcomes.

Conclusions and Relevance

In this study of older hospitalized patients, CMR plus postdischarge follow-up did not decrease the incidence of unplanned hospital visits. The findings do not support the performance of hospital-based CMRs as conducted in this trial. Alternative forms of medication reviews that aim to improve older patients' health outcomes should be considered and subjected to randomized clinical trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT02986425.

Effects of neurological music therapy on behavioural and emotional recovery after traumatic brain injury: A randomized controlled cross-over trial

Traumatic brain injury (TBI) causes deficits in executive function (EF), as well as problems in behavioural and emotional self-regulation. Neurological music therapy may aid these aspects of recovery. We performed a cross-over randomized controlled trial where 40 persons with moderate-severe TBI received a 3-month neurological music therapy intervention (2 times/week, 60 min/session), either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. The evidence from this RCT previously demonstrated that music therapy enhanced general EF and set shifting. In the current study, outcome was assessed with self-report and caregiver-report questionnaires performed at baseline, 3-month, 6-month, and 18-month stages. The results showed that the self-reported Behavioural Regulation Index of the Behaviour Rating Inventory of Executive Function (BRIEF-A) improved more in the AB than BA group from baseline to 3-month stage and the effect was maintained in the 6-month follow-up. No changes in mood or quality of life questionnaires were observed. However, a qualitative content analysis of the feedback revealed that many participants experienced the intervention as helpful in terms of emotional well-being and activity. Our results suggest that music therapy has a positive effect on everyday behavioural regulation skills after TBI.

The Addition of Real-time Ultrasound Visual Feedback to Manual Facilitation Increases Serratus Anterior Activation in Adults With Painful Shoulders: A Randomized Crossover Trial

OBJECTIVE

Serratus anterior (SA) muscle activation may be decreased with subacromial pain syndrome. The purpose of this study was to determine whether the addition of real-time ultrasound (RTUS) visual feedback increased activation of SA in adults with painful shoulders in comparison to manual facilitation alone.

METHODS

This assessor-blinded, 2-period, randomized cross-over trial was conducted in a university medical imaging laboratory. Adults with mild-moderate unilateral subacromial pain received both interventions in random order with at least 1-week washout between interventions. Fourteen participants were randomized to receive manual facilitation with RTUS first, and 13 were randomized to receive manual facilitation alone first. Fifteen repetitions of a supine ``serratus punch'' were facilitated by RTUS visual feedback with manual facilitation or by manual facilitation alone. Levels of SA activation via surface electromyography were normalized to a maximum voluntary isometric contraction.

RESULTS

A total of 25 participants completed the full trial of both interventions. Data from 25 participant periods for RTUS with manual facilitation and data from 26 participant periods for manual facilitation only were analyzed. The predicted marginal mean difference between interventions was 55.5% (95% CI = 13.9% to 97.1%) in favor of the addition of RTUS feedback. No adverse effects occurred.

CONCLUSION

RTUS visual feedback increases SA activation in adults with painful shoulders compared with manual facilitation alone.

IMPACT

Determining if RTUS can improve SA muscle activation may help clinicians improve physical therapist interventions for subacromial pain syndrome.

The MiaoMiao study: can do-it-yourself continuous glucose monitoring technology improve fear of hypoglycaemia in parents of children affected by type 1 diabetes?

Purpose

Type 1 diabetes (T1D) is one of the most common chronic diseases of childhood and comes with considerable management and psychological burden for children and their families. Fear of hypoglycaemia (FOH), particularly nocturnal hypoglycaemia, is a common worry. Continuous glucose monitoring (CGM) is a tool that may help reduce FOH, as well as reduce overall diabetes burden. However, CGM systems are expensive and often not publicly funded or subsidised. MiaoMiao (MM) is a novel relatively affordable third-party add-on technology to intermittently scanned CGM (isCGM). MM allows users to convert their isCGM to a form of "Do-it-yourself" (DIY)-CGM. Our hypothesis is that MM-CGM will result in significant reduction in parental fear from hypoglycaemia. The primary objective is to determine the impact of real-time DIY-CGM on parental fear of hypoglycaemia using Hypoglycaemia Fear Survey (HFS).

Methods

This is a multisite randomised cross-over study of 55 New Zealand children (ages 2-13 years) with established T1D and current users of isCGM (Abbott FreeStyle Libre). DIY-CGM will be compared to usual care with isCGM. Participants will be randomised to either arm of the study for 6 weeks followed by a 4-week wash-out period before crossing over to the other study arm for a further 6 weeks.

Discussion

The results of this study will provide much needed clinical trial data regarding DIY-CGM effectiveness in reducing parental FOH, as measured by HFS, as well as various other secondary outcomes including traditional glycaemic metrics, and child and caregiver sleep. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12619001551189) on 18 November 2019, and the World Health Organisation International Clinical Trial Registry Platform (Universal Trial Number U1111-1236-9189).

Effects of Exercise Mode on Arterial Stiffness in Symptomatic Peripheral Artery Disease Patients: A Randomized Crossover Clinical Trial

BACKGROUND

Exercise program has been recommended for the treatment of symptomatic peripheral artery disease (PAD) patients. However, whether exercise promotes reduction in arterial stiffness in these patients, who exhibit high arterial stiffness, is poor known.

AIM

To analyze the effects of a single session of resistance, walking, and combined exercises on arterial stiffness in symptomatic PAD patients and to describe individual responses and identify clinical predictors of arterial stiffness responses after exercises.

METHODS

Twelve patients with symptomatic PAD underwent four experimental sessions in random order: walking exercise (W - 10 bouts of 2-min walking at the speed corresponding to the onset of claudication pain with 2-min interval among sets), resistance exercise (R - 2 sets of 10 reps in eight resistance exercises), combined exercise (CO - 1 set of 10 reps in eight resistance exercises + 5 bouts of 2-min walking with 2-min interval between) and control session (C - resting in exercise room). Ambulatory arterial stiffness index (AASI) was obtained during ambulatory period after each session. Body mass index, ankle brachial index, sex and age also were evaluated.

RESULTS

AASI was lower in R compared to other sessions (R - 0.52 ± 0.05; W - 0.59 ± 0.05; CO - 0.64 ± 0.05; C - 0.60 ± 0.05, P < 0.001), with 75% of patients presenting lower AASI after R session. No difference was found between W, CO and C sessions (P> 0.05). Ankle brachial index was negatively correlated with R and W sessions net effect (r = -0.618 and -0.750, respectively; P< 0.05 for both), no correlation was found with CO.

CONCLUSION

A single bout of resistance exercise acutely reduces arterial stiffness in symptomatic PAD, while walking and combined exercise did not alter this variable. This response is more likely to occur in individuals with less severe disease.

Effect of Exposure to e-Cigarettes With Salt vs Free-Base Nicotine on the Appeal and Sensory Experience of Vaping: A Randomized Clinical Trial

IMPORTANCE

Alkaline free-base nicotine is bitter and a respiratory irritant. High-nicotine electronic cigarette (e-cigarette) products contain acid additives that change nicotine from a free-base to a protonated salt chemical form, which could improve the sensory experience of vaping, particularly among never smokers unaccustomed to inhaling free-base nicotine.

OBJECTIVE

To determine whether exposure to e-cigarettes with salt vs free-base nicotine formulations improves the appeal and sensory experience of vaping e-cigarettes and whether nicotine formulation effects differ by e-cigarette flavor and ever combustible cigarette smoking status.

DESIGN, SETTING, AND PARTICIPANTS

Single-visit double-blind within-participant randomized clinical trial was conducted in an academic medical center outpatient clinical research facility in Southern California. Participants were 119 individuals with past 30-day e-cigarette or combustible cigarette use aged 21 years or older recruited from November 2019 to March 2020.

INTERVENTIONS

Participants self-administered standardized puffs of each 10 differently flavored e-cigarette solutions using a pod-style device. Each flavor was administered in salt (benzoic acid added) and free-base (no benzoic acid) nicotine formulations with commensurate nicotine concentrations (mean, 23.6 mg/mL). The 20 solutions were administered in randomly assigned sequences. Immediately after puffing each solution, participants rated appeal and sensory attributes.

MAIN OUTCOMES AND MEASURES

Self-reported appeal (mean of like, dislike [reverse-scored], and willingness to use again ratings) and 4 sensory attributes (sweetness, smoothness, bitterness, and harshness; analyzed individually) on visual analog scales with not at all and extremely anchors (range, 0-100).

RESULTS

Of the 119 participants; 39 (32.8%) were female. The mean (SD) age was 42.1 (14.4) years; 105 (88.2%) were ever combustible cigarette smokers, and 66 (55.5%) were current e-cigarette users. Salt vs free-base nicotine formulations produced higher ratings of appeal (salt vs free-base mean difference effect estimate: b = 12.0; 95% CI, 9.9-14.1; P < .001), sweetness (b = 9.3; 95% CI, 7.1-11.4; P < .001), and smoothness (b = 17.4; 95% CI, 15.2-19.6; P < .001) and lower ratings of bitterness (b = -13.3; 95% CI, -15.4 to -11.2; P < .001) and harshness (b = -21.0; 95% CI, -23.2 to -18.7; P < .001). Nicotine formulation effects largely generalized across different flavors and the smoothness-enhancing and harshness-reducing effects of nicotine salt were stronger in never vs ever cigarette smokers.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of adult current nicotine or tobacco product users, controlled exposure to e-cigarette puffs with salt vs free-base nicotine formulations appeared to increase product appeal and improve the sensory experience of vaping, particularly among never smokers. Regulatory policies limiting acid additives in e-cigarettes might reduce the appeal of high-nicotine e-cigarettes among populations deterred from vaping e-cigarettes that emit harsh aerosol.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04399031.

Acute effects of 2D exergame on cognitive functions and frontal cortical activity

ABSTRACT This study aims to evaluate the effect of an exercise with a 2D virtual reality session on the cognition and cortical activity of young males. This is a randomized controlled trial with ten men aged 18 to 23 years. They were randomly assigned under two conditions: 1) exercise session with 2D virtual reality games and 2) control, which consisted of watching a two-episode video of a comic TV show. Cognition and frontal cortical activity were assessed immediately before and after the intervention, using the Mindset, performing the Digit Span Test, semantic verbal fluency, and executive function. Executive function improved with the exergame session (p=0.025). Exergames partially promote an immediate increase in the executive function of young people.

Beyond physiotherapy and pharmacological treatment for fibromyalgia syndrome: tailored tACS as a new therapeutic tool

Fibromyalgia syndrome (FMS) is a complex pain disorder, characterized by diffuse pain and cognitive disturbances. Abnormal cortical oscillatory activity may be a promising biomarker, encouraging non-invasive neurostimulation techniques as a treatment. We aimed to modulate abnormal slow cortical oscillations by delivering transcranial alternating current stimulation (tACS) and physiotherapy to reduce pain and cognitive symptoms. This was a double-blinded, randomized, crossover trial conducted between February and September 2018 at the Rehabilitation Unit of a teaching Hospital (NCT03221413). Participants were randomly assigned to tACS or random noise stimulation (RNS), 5 days/week for 2 weeks followed by ad hoc physiotherapy. Clinical and cognitive assessments were performed at T₀ (baseline), T₁ (after stimulation), T₂ (1 month after stimulation). Electroencephalogram (EEG) spectral topographies recorded from 15 participants confirmed slow-rhythm prevalence and provided tACS tailored stimulation parameters and electrode sites. Following tACS, EEG alpha1 ([8-10] Hz) activity increased at T₁ (p = 0.024) compared to RNS, pain symptoms assessed by Visual Analog Scale decreased at T₁ (T₁ vs T₀ p = 0.010), self-reported cognitive skills and neuropsychological scores improved both at T₁ and T₂ (Patient-Reported Outcomes in Cognitive Impairment, T₀-T₂, p = 0.024; Everyday memory questionnaire, T₁ compared to RNS, p = 0.012; Montréal Cognitive Assessment, T₀ vs T₁, p = 0.048 and T₀ vs T₂, p = 0.009; Trail Making Test B T₀-T₂, p = 0.034). Psychopathological scales and other neuropsychological scores (Trail Making Test-A; Total Phonemic Fluency; Hopkins Verbal Learning Test-Revised; Rey-Osterrieth Complex Figure) improved both after tACS and RNS but earlier improvements (T₁) were registered only after tACS. These results support tACS coupled with physiotherapy in treating FMS cognitive symptoms, pain and subclinical psychopathology.

TriMaster: randomised double-blind crossover study of a DPP4 inhibitor, SGLT2 inhibitor and thiazolidinedione as second-line or third-line therapy in patients with type 2 diabetes who have suboptimal glycaemic control on metformin treatment with or without a sulfonylurea-a MASTERMIND study protocol

INTRODUCTION

Pharmaceutical treatment options for patients with type 2 diabetes mellitus (T2DM) have increased to include multiple classes of oral glucose-lowering agents but without accompanying guidance on which of these may most benefit individual patients. Clinicians lack information for treatment intensification after first-line metformin therapy. Stratifying patients by simple clinical characteristics may improve care by targeting treatment options to those in whom they are most effective. This academically designed and run three-way crossover trial aims to test a stratification approach using three standard oral glucose-lowering agents.

METHODS AND ANALYSIS

TriMaster is a randomised, double-blind, crossover trial taking place at up to 25 clinical sites across England, Scotland and Wales. 520 patients with T2DM treated with either metformin alone, or metformin and a sulfonylurea who have glycated haemoglobin (HbA1c) >58 mmol/mol will be randomised to receive 16 weeks each of a dipeptidyl peptidase-4 inhibitor, sodium-glucose co-transporter-2 inhibitor and thiazolidinedione in random order. Participants will be assessed at the end of each treatment period, providing clinical and biochemical data, and their experience of side effects. Participant preference will be assessed on completion of all three treatments. The primary endpoint is HbA1c after 4 months of therapy (allowing a range of 12-18 weeks for analysis). Secondary endpoints include participant-reported preference between the three treatments, tolerability and prevalence of side effects.

ETHICAL APPROVAL

This study was approved by National Health Service Health Research Authority Research Ethics Committee South Central-Oxford A, study 16/SC/0147. Written informed consent will be obtained from all participants. Results will be submitted to a peer-reviewed journal and presented at relevant scientific meetings. A lay summary of results will be made available to all participants.

TRIAL REGISTRATION NUMBERS

12039221; 2015-002790-38 and NCT02653209.

Evaluation of an effectiveness and safety of the electroacupuncture in the management of intractable neuropathic pain: A prospective, open-labeled, randomized, cross-over clinical trial

BACKGROUND

There is no sufficient evidence on the effectiveness of acupuncture for neuropathic pain. This protocol describes a study that aims to evaluate the effectiveness and safety of electroacupuncture combined with conventional medicine for patients with intractable neuropathic pain, when compared with conventional medicine alone.

METHODS/DESIGN

This study is a prospective, open-labeled, randomized, cross-over clinical trial. A total of 40 patients with neuropathic pain who had a numeric rating scale (NRS) score of over 4 despite receiving conventional treatment for more than 3 months will be enrolled. Participants will receive conventional treatment for neuropathic pain (treatment C) or treatment C combined with 12 additional sessions of electroacupuncture treatment (treatment A) for 6 weeks. Participants will be randomly assigned to 1 of the 2 sequence groups (AC and CA group) with a 1:1 allocation. The differences of responder in the composite efficacy outcomes, which consist of the NRS, Brief Pain Inventory-Short Form (BPI-SF) pain subscale, and global assessment at 6 weeks after randomization will be examined as the primary outcome. Secondary outcomes include differences in the NRS, the Short-Form McGill Pain Questionnaire, BPI-SF, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Medical Outcomes Study Sleep Scale, global assessment, EQ-5D, and incremental cost-effective ratio at 6 and 15 weeks after randomization. Adverse events, vital signs, and physical examinations will be recorded to evaluate safety.

DISCUSSION

The study protocol for this trial will provide up-to-date evidence on the effectiveness and safety of electroacupuncture for patients with intractable neuropathic pain. The results will be disseminated through a peer-reviewed journal and conference presentations.

TRIAL REGISTRATION

Clinical Research Information Service, ID: KCT0003615. Registered on March 12, 2019. https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=13410& ltype=&rtype=.

A Randomized Controlled Trial to Assess the Effect of Lidocaine Administered via Throat Spray and Nebulization in Patients with Refractory Chronic Cough

BACKGROUND

Refractory chronic cough (RCC) is a debilitating condition for which there are no licensed treatments. Lidocaine is a nonselective inhibitor of voltage-gated sodium channels with potential antitussive effects, but randomized placebo-controlled studies evaluating its efficacy in RCC are lacking.

OBJECTIVE

To investigate the efficacy of nebulized lidocaine and lidocaine throat spray versus matched placebos in RCC.

METHODS

This was a randomized, double-blind, double-dummy, placebo-controlled, 3-way crossover study, comparing the effect of single doses of nebulized lidocaine with lidocaine delivered by a throat spray and matched placebo. The primary end point was cough frequency over the 10 hours following treatment. Secondary end points were visual analog scale scores for urge-to-cough and cough severity; an exploratory analysis evaluated hourly cough rates up to 5 hours after treatment.

RESULTS

Twenty-six subjects with RCC were recruited (22 females; mean age, 53.5 ± 12.1 years; FEV₁ %predicted, 105.2 ± 16.8 L; forced vital capacity %predicted, 112.4 ± 18 L). Lidocaine throat spray, but not nebulized lidocaine, significantly reduced 10-hour cough frequency as compared with placebo (throat spray, 22.6 coughs/h; nebulization, 26.9 coughs/h; and placebos, 27.6 coughs/h; P = .04,). Lidocaine throat spray showed the greatest effect on cough compared with placebo in the first hour after administration (31.7 coughs/h vs 74.2 coughs/h; P = .004). Both nebulizer and spray treatments significantly alleviated urge-to-cough and cough severity visual analog scale scores compared with placebo (P < .05). There were no serious adverse events associated with lidocaine therapy.

CONCLUSIONS

Lidocaine throat spray was effective in reducing cough frequency in patients with RCC. Voltage-gated sodium channel inhibitors applied to pharynx have potential as therapies for RCC.

Guidelines for reporting randomized controlled trials in paediatric dentistry based on the CONSORT statement

BACKGROUND

The significance of randomized controlled trials (RCT) depends on how thoroughly the results were reported. Reporting of RCTs should be accurate and transparent and encompasses design, implementation, analysis, and results of the trial. The Consolidated Standards of Reporting Trials (CONSORT) statement and its extension were developed to guide the researchers to report clinical trials in a systematic manner. Despite this recommendation, the overall reporting quality of RCTs still remains suboptimal.

AIM

To describe the relevance and importance of CONSORT reporting guidelines and explain the items using examples derived from randomized trials published in Paediatric Dentistry.

METHODS

This is a narrative review that illustrates the importance of reporting items in the CONSORT guidelines from relevant sources. RCTs published in the International Journal of Paediatric Dentistry between 2017 and 2020 were identified from PubMed and Scopus databases and through handsearching. An explanation has been provided for each of the 37 items in the 2010 CONSORT checklist and 17 items in the CONSORT extension for reporting abstracts.

CONCLUSION

This explanation and elaboration document would enable investigators to report trials in Paediatric Dentistry with accuracy and transparency as well as for reviewers and editors in evaluating the suitability of RCTs for publication.

Analgesic Efficacy of "Burst" and Tonic (500 Hz) Spinal Cord Stimulation Patterns: A Randomized Placebo-Controlled Crossover Study

OBJECTIVES

The aim of this study was to compare the efficacy in reducing pain intensity in adult subjects suffering from chronic back and leg pain of burst (BST) and tonic sub-threshold stimulation at 500 Hz (T500) vs. sham stimulation delivered by a spinal cord stimulation (SCS) device capable of automated postural adjustment of current intensity.

MATERIALS AND METHODS

A multicentre randomized double-blind, three-period, three-treatment, crossover study was undertaken at two centers in the United Kingdom. Patients who had achieved stable pain relief with a conventional SCS capable of automated postural adjustment of current intensity were randomized to sequences of BST, T500, and sham SCS with treatment order balanced across the six possible sequences. A current leakage was programmed into the implantable pulse generator (IPG) in the sham period. The primary outcome was patient reported pain intensity using a visual analog scale (VAS).

RESULTS

Nineteen patients were enrolled and randomized. The mean reduction in pain with T500 was statistically significantly greater than that observed with either sham (25%; 95% CI, 8%-38%; p = 0.008) or BST (28%; 95% CI, 13%-41%; p = 0.002). There were no statistically significant differences in pain VAS for BST versus Sham (5%; 95% CI, -13% to 27%; p = 0.59). Exploratory sub-group analyses by study site and sex were also conducted for the T500 vs. sham and BST versus sham comparisons.

CONCLUSIONS

The findings suggest a superior outcome versus sham from T500 stimulation over BST stimulation and a practical equivalence between BST and sham in a group of subjects with leg and back pain habituated to tonic SCS and having achieved a stable status with stimulation.

Influence of Lumbar Mobilizations During the Nordic Hamstring Exercise on Hamstring Measures of Knee Flexor Strength, Failure Point, and Muscle Activity: A Randomized Crossover Trial

OBJECTIVE

The aims of this study were to quantify the effects of spinal mobilization on force production, failure point, and muscle activity of the hamstrings during the Nordic hamstring exercise (NHE), and to explore individual differences in responses.

METHODS

In a replicated randomized crossover trial, 24 asymptomatic, recreationally active men (age [mean ± standard deviation]: 27 ± 6 years; body mass: 82 ± 17 kg; height: 181 ± 8 cm) completed 2 standardized intervention trials (L4/5 zygapophyseal mobilizations) and 2 control trials. The failure point of the NHE was determined with 3D motion capture. Peak force, knee flexor torque, and electromyography (EMG) of the biceps femoris were measured. Data analyses were undertaken to quantify mean intervention response and explore any individual response heterogeneity.

RESULTS

Mean (95% confidence interval) left-limb force was higher in intervention than in control trials by 18.7 (4.6-32) N. Similarly, right-limb force was higher by 22.0 (3.4-40.6) N, left peak torque by 0.14 (0.06-0.22) N • m, and right peak torque by 0.14 (0.05-0.23) N • m/kg. Downward force angle was decreased in intervention vs control trials by 4.1° (0.5°-7.6°) on the side of application. Both peak EMG activity (P = .002), and EMG at the downward force (right; P = .020) increased in the intervention condition by 16.8 (7.1-26.4) and 8.8 (1.5-16.1) mV, respectively. Mean downward acceleration angle changed by only 0.3° (-8.9° to 9.4°) in intervention vs control trials. A clear response heterogeneity was indicated only for right force (Participant × Intervention interaction: P = .044; response heterogeneity standard deviation = 34.5 [5.7-48.4] N). Individual response heterogeneity was small for all other outcomes.

CONCLUSION

After spinal mobilization, immediate changes in bilateral hamstring force production and peak torque occurred during the NHE. The effect on the NHE failure point was unclear. Electromyographic activity increased on the ipsilateral side. Response heterogeneity was generally similar to the random trial-to-trial variability inherent in the measurement of the outcomes.

Whole-Body Vibration as Antihypertensive Non-Pharmacological Treatment in Hypertensive Individuals with Knee Osteoarthritis: Randomized Cross-Over Trial

(1) Background: Hypertension is a serious medical condition characterized by a persistent increase in blood pressure (BP), which is prevalent in individuals with knee osteoarthritis (KOA). Pharmacological interventions are normally used to treat both hypertension and KOA; however, a more sustainable form of treatment is desirable for these clinical conditions. Whole-body vibration (WBV) exercise has been proposed as a non-pharmacological therapy for reducing both BP and KOA symptomatology. This study aimed to evaluate the antihypertensive effect of WBV in hypertensive individuals with KOA. (2) Methods: Nineteen hypertensive individuals with KOA were randomly allocated to either a control (CG) (n = 9) or a WBV group (WBVG) (n = 10). Subjects in the WBVG were positioned sitting in a chair in front of a vibrating platform (VP) with the feet on the base (peak-to-peak displacement 2.5, 5.0 and 7.5 mm; frequencies 5 to 14 Hz). In the CG, subjects assumed the same position with the VP turned off. The protocols in the CG and WBVG were performed 2 days/week for a total of 5 weeks. (3) Results: No baseline differences (age, anthropometrics, BP parameters and medications) between the groups were found (p > 0.05). WBV exercise reduced systolic BP (SBP: 126.1 ± 2.7 versus 119.1 ± 3.2 mmHg; p = 0.001; post hoc: p = 0.02; F = 23.97) and mean BP (MBP: 82.6 ± 1.8 versus 78.7 ± 1.8, p = 0.001, post hoc: p = 0.02; F = 23.97), while no significant changes were found in diastolic BP (DBP: 68.5 ± 2.2 versus 64.4 ± 2.3; p = 0.11; F = 2.68). (4) Conclusions: WBV might be considered a sustainable therapy for exerting an antihypertensive effect in medicated hypertensive individuals with KOA. This decline in BP might translate to a reduction in pharmacological need, although further studies are necessary to understand the mechanisms underlying the described effect.

Virtual reality distraction for acute pain in children

BACKGROUND

Virtual reality (VR) computer technology creates a simulated environment, perceived as comparable to the real world, with which users can actively interact. The effectiveness of VR distraction on acute pain intensity in children is uncertain.

OBJECTIVES

To assess the effectiveness and adverse effects of virtual reality (VR) distraction interventions for children (0 to 18 years) with acute pain in any healthcare setting.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and four trial registries to October 2019. We also searched reference lists of eligible studies, handsearched relevant journals and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cross-over and cluster-RCTs, comparing VR distraction to no distraction, non-VR distraction or other VR distraction.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological processes. Two reviewers assessed risk of bias and extracted data independently. The primary outcome was acute pain intensity (during procedure, and up to one hour post-procedure). Secondary outcomes were adverse effects, child satisfaction with VR, pain-related distress, parent anxiety, rescue analgesia and cost. We used GRADE and created 'Summary of findings' tables.

MAIN RESULTS

We included 17 RCTs (1008 participants aged four to 18 years) undergoing various procedures in healthcare settings. We did not pool data because the heterogeneity in population (i.e. diverse ages and developmental stages of children and their different perceptions and reactions to pain) and variations in procedural conditions (e.g. phlebotomy, burn wound dressings, physical therapy sessions), and consequent level of pain experienced, made statistical pooling of data impossible. We narratively describe results. We judged most studies to be at unclear risk of selection bias, high risk of performance and detection bias, and high risk of bias for small sample sizes. Across all comparisons and outcomes, we downgraded the certainty of evidence to low or very low due to serious study limitations and serious or very serious indirectness. We also downgraded some of the evidence for very serious imprecision. 1: VR distraction versus no distraction Acute pain intensity: during procedure Self-report: one study (42 participants) found no beneficial effect of non-immersive VR (very low-certainty evidence). Observer-report: no data. Behavioural measurements (observer-report): two studies, 62 participants; low-certainty evidence. One study (n = 42) found no beneficial effect of non-immersive VR. One study (n = 20) found a beneficial effect favouring immersive VR. Acute pain intensity: post-procedure Self-report: 10 studies, 461 participants; very low-certainty evidence. Four studies (n = 95) found no beneficial effect of immersive and semi-immersive or non-immersive VR. Five studies (n = 357) found a beneficial effect favouring immersive VR. Another study (n = 9) reported less pain in the VR group. Observer-report: two studies (216 participants; low-certainty evidence) found a beneficial effect of immersive VR, as reported by primary caregiver/parents or nurses. One study (n = 80) found a beneficial effect of immersive VR, as reported by researchers. Behavioural measurements (observer-report): one study (42 participants) found no beneficial effect of non-immersive VR (very low-certainty evidence). Adverse effects: five studies, 154 participants; very low-certainty evidence. Three studies (n = 53) reported no adverse effects. Two studies (n = 101) reported mild adverse effects (e.g. nausea) in the VR group. 2: VR distraction versus other non-VR distraction Acute pain intensity: during procedure Self-report, observer-report and behavioural measurements (observer-report): two studies, 106 participants: Self-report: one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) found no evidence of a difference in mean pain change scores (very low-certainty evidence). Observer-report: one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) found no evidence of a difference in mean pain change scores (low-certainty evidence). Behavioural measurements (observer-report): one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) reported a difference in mean pain change scores with fewer pain behaviours in VR group (low-certainty evidence). Acute pain intensity: post-procedure Self-report: eight studies, 575 participants; very low-certainty evidence. Two studies (n = 146) found a beneficial effect favouring immersive VR. Two studies (n = 252) reported a between-group difference favouring immersive VR. One study (n = 59) found no beneficial effect of immersive VR versus television and Child Life non-VR distraction. One study (n = 18) found no beneficial effect of semi-immersive VR. Two studies (n = 100) reported no between-group difference. Observer-report: three studies, 187 participants; low-certainty evidence. One study (n = 81) found a beneficial effect favouring immersive VR for parent, nurse and researcher reports. One study (n = 65) found a beneficial effect favouring immersive VR for caregiver reports. Another study (n = 41) reported no evidence of a difference in mean pain change scores. Behavioural measurements (observer-report): two studies, 106 participants; low-certainty evidence. One study (n = 65) found a beneficial effect favouring immersive VR. Another study (n = 41) reported no evidence of a difference in mean pain change scores. Adverse effects: six studies, 429 participants; very low-certainty evidence. Three studies (n = 229) found no evidence of a difference between groups. Two studies (n = 141) reported no adverse effects in VR group. One study (n = 59) reported no beneficial effect in reducing estimated cyber-sickness before and after VR immersion. 3: VR distraction versus other VR distraction We did not identify any studies for this comparison.

AUTHORS' CONCLUSIONS

We found low-certainty and very low-certainty evidence of the effectiveness of VR distraction compared to no distraction or other non-VR distraction in reducing acute pain intensity in children in any healthcare setting. This level of uncertainty makes it difficult to interpret the benefits or lack of benefits of VR distraction for acute pain in children. Most of the review primary outcomes were assessed by only two or three small studies. We found limited data for adverse effects and other secondary outcomes. Future well-designed, large, high-quality trials may have an important impact on our confidence in the results.

Beyond Journals-Visual Abstracts Promote Wider Suicide Prevention Research Dissemination and Engagement: A Randomized Crossover Trial

Background: Many academic institutions and journals disseminate research through social media to increase accessibility and reach a wider audience. "Visual Abstracts" are well-suited for social media dissemination, and have been adopted by some as a novel approach to increase engagement with academic content. Visual abstracts are a visual representation of key methods and findings from a traditional peer-reviewed publication. This study expands on previous research by examining the impact of visual abstracts compared to traditional text abstracts to disseminate research produced in a national research center focused on preventing Veteran suicide. Methods: A prospective, randomized crossover design was utilized to compare Twitter posts with a visual abstract to those with a simple screen grab of the PubMed abstract (n = 50 journal publications). Outcomes were measured using native Twitter Analytics to track impressions, retweets, total engagements, and link clicks about 28 days post-tweet, and Altmetric It to track additional alternative metric outcomes. Results: Visual abstract tweets were associated with a significantly higher number of impressions (p < 0.001), retweets (p < 0.001), and link clicks (p = 0.02) compared with text abstract tweets. Conclusions: In line with results from prior studies, we found that visual abstracts resulted in significantly greater research dissemination and social media engagement via retweets and link clicks compared with text tweets. These findings provide further evidence that visual abstracts increase awareness and readership of journal publications, and that Twitter is an effective platform for research dissemination beyond the traditional academic researcher audience. Implications highlight the importance of social media for suicide prevention advocates, Veteran health researchers and other stakeholders to communicate research findings.

The impact of regular bisoprolol on the response to salbutamol in asthma: A double-blind randomized placebo-controlled crossover trial

BACKGROUND AND OBJECTIVE

Non-selective beta-blockers impair the bronchodilator response to beta₂ -agonists. Cardio-selective beta₁ -blockers are less likely to cause this effect, yet they remain relatively contraindicated in asthma. We investigated whether the response to salbutamol is impaired during cardio-selective beta₁ -blocker treatment in people with asthma.

METHODS

A random-order, double-blind, placebo-controlled, non-inferiority, crossover study was conducted comparing up to 5 mg bisoprolol daily for 2 weeks with matching placebo, with an open-label extension of up to 10 mg bisoprolol daily. After each treatment period, mannitol was inhaled to induce bronchoconstriction with a 15% fall in forced expiratory volume in 1 s (FEV₁ ). Immediately after mannitol challenge, salbutamol (100, 100 and 200 μg) was administered via spacer at 5-min intervals with repeated FEV₁ measures. The FEV₁ recovery with salbutamol was measured as an area under recovery curve (AUC). Based on earlier research, a clinically relevant non-inferiority limit of a 30% reduction in the AUC was set.

RESULTS

A total of 19 adults with mild asthma and positive inhaled mannitol challenge completed the study. Adjusting for the FEV₁ fall induced by mannitol and treatment sequence, the mean AUC response to salbutamol after bisoprolol was 5% lower than after placebo, with a one-sided 95% confidence interval (CI) of 26% lower. Thirteen participants completed the open-label extension up to 10 mg bisoprolol daily with mean AUC 11% higher after bisoprolol with a 95% CI of 5% lower.

CONCLUSION

The bronchodilator response to rescue salbutamol after mannitol-induced bronchoconstriction is non-inferior during regular treatment with the cardio-selective beta₁ -blocker, bisoprolol, compared to placebo.

CLINICAL TRIAL REGISTRATION

ACTRN12618000306213 at https://www.anzctr.org.au.

The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study

BACKGROUND

Worldwide, music is commonly played in the operation room. The effect of music on surgical performance reportedly has varying results, while its effect on mental workload and key surgical stressor domains has only sparingly been investigated. Therefore, the aim is to assess the effect of recorded preferred music versus operating room noise on laparoscopic task performance and mental workload in a simulated setting.

METHODS

A four-sequence, four-period, two-treatment, randomized controlled crossover study design was used. Medical students, novices to laparoscopy, were eligible for inclusion. Participants were randomly allocated to one of four sequences, which decided the exposure order to music and operation room noise during the four periods. Laparoscopic task performance was assessed through motion analysis with a laparoscopic box simulator. Each period consisted of ten alternating peg transfer tasks. To account for the learning curve, a preparation phase was employed. Mental workload was assessed using the Surgery Task Load Index. This study was registered with the Netherlands Trial Register (NL7961).

RESULTS

From October 29, 2019 until March 12, 2020, 107 participants completed the study, with 97 included for analyzation. Laparoscopic task performance increased significantly during the preparation phase. No significant beneficial effect of music versus operating room noise was observed on time to task completion, path length, speed, or motion smoothness. Music significantly decreased mental workload, reflected by a lower score of the total weighted Surgery Task Load Index in all but one of the six workload dimensions.

CONCLUSION

Music significantly reduced mental workload overall and of several previously identified key surgical stressor domains, and its use in the operating room is reportedly viewed favorably. Music did not significantly improve laparoscopic task performance of novice laparoscopists in a simulated setting. Although varying results have been reported previously, it seems that surgical experience and task demand are more determinative.

Effect of ultrafiltration profiling on outcomes among maintenance hemodialysis patients: a pilot randomized crossover trial

BACKGROUND

More rapid fluid removal during hemodialysis is associated with adverse cardiovascular outcomes and longer dialysis recovery times. The effect of ultrafiltration (UF) profiling, independent of concomitant sodium profiling, on markers of intradialytic hemodynamics and other outcomes has been inadequately studied.

METHODS

Four-phase, blinded crossover trial. Participants (UF rates > 10 mL/h/kg) were assigned in random order to receive hemodialysis with UF profiling (constantly declining UF rate, intervention) vs. hemodialysis with conventional UF (control). Each 3-week 9-treatment period was followed by a 1-week 3-treatment washout period. Participants crossed into each study arm twice (2 phases/arm); 18 treatments per treatment type. The primary outcomes were intradialytic hypotension, pre- to post-dialysis troponin T change, and change from baseline in left ventricular global longitudinal strain. Other outcomes included intradialytic symptoms and blood volume measured-plasma refill (post-dialysis volume status measure), among others. Each participant served as their own control.

RESULTS

On average, the 34 randomized patients (mean age 56 years, 24% female, mean dialysis vintage 6.3 years) had UF rates > 10 mL/h/kg in 56% of treatments during the screening period. All but 2 patients completed the 15-week study (prolonged hospitalization, kidney transplant). There was no significant difference in intradialytic hypotension, troponin T change, or left ventricular strain between hemodialysis with UF profiling and conventional UF. With UF profiling, participants had significantly lower odds of light-headedness and plasma refill compared to hemodialysis with conventional UF.

CONCLUSIONS

Ultrafiltration (UF) profiling did not reduce the odds of treatment-related cardiac stress but did reduce the odds of light-headedness and post-dialysis hypervolemia.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03301740 (registered October 4, 2017).

Effects of cerebellar transcranial magnetic stimulation on ataxias: A randomized trial

INTRODUCTION

Cerebellar ataxia remains a neurological symptom orphan of treatment interventions, despite being prevalent and incapacitating. We aimed to study, in a double-blind design, whether cerebellar modulation could improve ataxia.

METHODS

We included patients with diagnosis of spinocerebellar ataxia type 3, multiple systems atrophy cerebellar type, or post-lesion ataxia. Patients received five sessions each of sham and active cerebellar 1 Hz deep repetitive transcranial magnetic stimulation in randomized order. Our primary outcome was the decrease in the Scale for the Assessment and Rating of Ataxia when comparing phases (active x sham). Secondary outcomes measures included the International Cooperative Ataxia Rating Scale, and other motor, cognitive, and quality of life scales. This study was registered at clinicaltrials.gov (protocol NCT03213106).

RESULTS

Twenty-four patients aged 29-74 years were included in our trial. After active stimulation, the Scale for the Assessment and Rating of Ataxia score was significantly lower than the score after sham stimulation [median (interquartile range) of 10.2 (6.2, 16.2) versus 12.8 (9.6, 17.8); p = 0.002]. The International Cooperative Ataxia Rating Scale score also improved after active stimulation versus sham [median (interquartile range) of 29.0 (21.0, 43.5) versus 32.8 (22.0, 47.0); p = 0.005]. Other secondary outcomes were not significantly modified by stimulation. No patient presented severe side effects, and nine presented mild and self-limited symptoms.

CONCLUSIONS

Our protocol was safe and well-tolerated. These findings suggest that cerebellar modulation may improve ataxic symptom and provide reassurance about safety for clinical practice.

Sub-Perception and Supra-Perception Spinal Cord Stimulation in Chronic Pain Syndrome: A Randomized, Semi-Double-Blind, Crossover, Placebo-Controlled Trial

BACKGROUND

The introduction of modern sub-perception modalities has improved the efficacy of spinal cord stimulation (SCS) in refractory pain syndromes of the trunk and lower limbs. The objective of this study was to evaluate the effectiveness of low and high frequency SCS among patients with chronic pain.

MATERIAL AND METHODS

A randomised, semi-double-blind, placebo controlled, four period (4 × 2 weeks) crossover trial was conducted from August 2018 to January 2020. Eighteen patients with SCS due to failed back surgery syndrome and/or complex regional pain syndrome were randomised to four treatment arms without washout periods: (1) low frequency (40-60 Hz), (2) 1 kHz, (3) clustered tonic, and (4) sham SCS (i.e., placebo). The primary outcome was pain scores measured by visual analogue scale (VAS) preoperatively and during subsequent treatment arms.

RESULTS

Pain scores (VAS) reported during the preoperative period was M (SD) = 8.13 (0.99). There was a 50% reduction in pain reported in the low frequency tonic treatment group (M (SD) = 4.18 (1.76)), a 37% reduction in the 1 kHz treatment group (M (SD) = 5.17 (1.4)), a 34% reduction in the clustered tonic settings group (M (SD) = 5.27 (1.33)), and a 34% reduction in the sham stimulation group (M (SD) = 5.42 (1.22)). The reduction in pain from the preoperative period to the treatment period was significant in each treatment group (p < 0.001). Overall, these reductions were of comparable magnitude between treatments. However, the modality most preferred by patients was low frequency (55% or 10 patients).

CONCLUSIONS

The pain-relieving effects of SCS reached significance and were comparable across all modes of stimulation including sham. Sub-perception stimulation was not superior to supra-perception. SCS was characterised by a high degree of placebo effect. No evidence of carryover effect was observed between subsequent treatments. Contemporary neuromodulation procedures should be tailored to the individual preferences of patients.

Long-term effects of resveratrol on cognition, cerebrovascular function and cardio-metabolic markers in postmenopausal women: A 24-month randomised, double-blind, placebo-controlled, crossover study

Ageing and menopause contribute to endothelial dysfunction, causing impaired cerebral perfusion, which is in turn associated with accelerated cognitive decline. In a 14-week pilot study, we showed that supplementation with low-dose resveratrol, a phytoestrogen that can enhance endothelial function, improved cerebrovascular and cognitive functions in postmenopausal women. We sought to confirm these benefits in a larger, longer-term trial. A 24-month randomized, placebo-controlled crossover trial was undertaken in 125 postmenopausal women, aged 45-85 years, who took 75 mg trans-resveratrol or placebo twice-daily for 12 months and then crossover to the alternative treatment for another 12 months. We evaluated within individual differences between each treatment period in measures of cognition (primary outcome), cerebrovascular function in the middle cerebral artery (cerebral blood flow velocity: CBFV, cerebrovascular responsiveness: CVR) and cardio-metabolic markers as secondary outcomes. Subgroup analyses examined effects of resveratrol by life stages. Compared to placebo, resveratrol supplementation resulted a significant 33% improvement in overall cognitive performance (Cohen's d = 0.170, P = 0.005). Women ≥65 years of age showed a relative improvement in verbal memory with resveratrol compared to those younger than 65 years. Furthermore, resveratrol improved secondary outcomes including resting mean CBFV (d = 0.275, P = 0.001), CVR to hypercapnia (d = 0.307, P = 0.027), CVR to cognitive stimuli (d = 0.259, P = 0.032), fasting insulin (d = 0.174, P = 0.025) and insulin resistance index (d = 0.102, P = 0.034). Regular supplementation with low-dose resveratrol can enhance cognition, cerebrovascular function and insulin sensitivity in postmenopausal women. This may translate into a slowing of the accelerated cognitive decline due to ageing and menopause, especially in late-life women. Further studies are warranted to observe whether these cognitive benefits of resveratrol can reduce the risk of dementia.

Prophylactic action of lipid and non-lipid tear supplements in adverse environmental conditions: A randomised crossover trial

PURPOSE

To evaluate the prophylactic benefits of lipid-based and non-lipid-based artificial tear lubricants, in dry eye disease, after adverse environmental exposure.

METHODS

Twenty-eight participants with dry eye disease were recruited in a prospective, double-masked, randomised crossover trial. On separate days, participants were randomised to receive a single application of a lipid-containing tear supplement (Systane Complete) to one eye, and a non-lipid containing eye drop (Systane Ultra) to the contralateral eye. Participants were then exposed to a previously validated simulated adverse environment. Symptoms, non-invasive tear film breakup time, lipid layer grade, and tear meniscus height were assessed at three time points; baseline, following eye drop instillation, and after exposure to the adverse environment.

RESULTS

Both treatments effected improvements in symptoms and non-invasive tear film stability following instillation (all p < 0.05), although an improvement in lipid layer quality was limited to the lipid-containing nano-emulsion tear supplement (p = 0.003). Although protective effects were conferred by both treatments following exposure to the simulated adverse environment, more favourable symptomology scores, non-invasive tear film stability, and lipid layer quality were observed in the lipid-containing tear supplement group (all p < 0.05). No significant changes were observed in tear meniscus height in both treatment groups (all p > 0.05).

CONCLUSIONS

Both the lipid and non-lipid-based artificial tear supplement demonstrated prophylactic benefits in a simulated adverse environment. However, the ability to preserve tear film quality and reduce dry eye symptomology was greater with the lipid-containing eye drop.

TRIAL REGISTRATION NUMBER

ACTRN12619000361101.

A randomized crossover trial to assess therapeutic efficacy and cost reduction of acid ursodeoxycholic manufactured by the university hospital for the treatment of primary biliary cholangitis

Background

Health care costs are growing faster than the rest of the global economy, according to the World Health Organization (WHO). Countries’ health expenditures include paying for general medicine, diagnostic procedures, hospitalizations and surgeries, as well as medications and prescribed treatment. Primary biliary cholangitis (PBC) is a rare autoimmune liver disease and the first line available treatment is ursodeoxycholic acid (UDCA), however, direct and indirect treatment costs are expensive. Main aim of this trial was to assess if the therapeutic efficacy of UDCA manufactured by the university hospital is equivalent to that of standard UDCA and treatment cost reduction in patients with PBC.

Methods

It is a prospective, interventional, randomized, and crossover study in patients diagnosed with PBC. UDCA 300 mg tablets and capsules were developed and manufactured by the university hospital. Thirty patients under treatment with standard UDCA, in stable doses were randomized in sequence A and B, 15 patients in each arm. The groups were treated for 12 weeks and after, the UDCA formulation was changed, following for another 12 weeks of continuous therapy (tablets and capsules / capsules and tablets). Laboratory tests were performed at time T0 (beginning of treatment), T1 (at the 12 week-therapy, before the crossing-over) and T2 (end of treatment). The evaluation was done by comparing the hepatic parameters ALP, GGT, ALT, AST and total bilirubin, also considering the adverse events. The comparison of costs was based on price of the manufactured UDCA and standard UDCA price of the hospital.

Results

Hospital reduced 66.1% the PBC treatment costs using manufactured UDCA. There were no differences in the biochemical parameters between sequence (A and B) and tablets or capsules of UDCA formulations applied in the treatment of PBC.

Conclusions

The study showed that there was no significant difference between manufactured UDCA (capsule and tablet) and standard UDCA. Hospital reduced the PBC treatment costs using the manufactured UDCA by the university hospital.

Trial registration

ClinicalTrials.gov: NCT03489889 retrospectively registered on January 12th, 2018; Ethics Committee approved the study (ID: 1.790.088) on October 25th, 2016.

Effects of dobutamine and phenylephrine on cerebral perfusion in patients undergoing cerebral bypass surgery: a randomised crossover trial

Background

Patients undergoing cerebral bypass surgery are prone to cerebral hypoperfusion. Currently, arterial blood pressure is often increased with vasopressors to prevent cerebral ischaemia. However, this might cause vasoconstriction of the graft and cerebral vasculature and decrease perfusion. We hypothesised that cardiac output, rather than arterial blood pressure, is essential for adequate perfusion and aimed to determine whether dobutamine administration resulted in greater graft perfusion than phenylephrine administration.

Methods

This randomised crossover study included 10 adult patients undergoing cerebral bypass surgery. Intraoperatively, patients randomly and sequentially received dobutamine to increase cardiac index or phenylephrine to increase mean arterial pressure (MAP). An increase of >10% in cardiac index or >10% in MAP was targeted, respectively. Before both interventions, a reference phase was implemented. The primary outcome was the absolute difference in graft flow between the reference and intervention phase. We compared the absolute flow difference between each intervention and constructed a random-effect linear regression model to explore treatment and carry-over effects.

Results

Graft flow increased with a median of 4.1 (inter-quartile range [IQR], 1.7–12.0] ml min⁻¹) after dobutamine administration and 3.6 [IQR, 1.3–7.8] ml min⁻¹ after phenylephrine administration (difference –0.6 ml min⁻¹; 95% confidence interval [CI], –14.5 to 5.3; P=0.441). There was no treatment effect (0.9 ml min⁻¹; 95% CI, 0.0–20.1; P=0.944) and no carry-over effect.

Conclusions

Both dobutamine and phenylephrine increased graft flow during cerebral bypass surgery, without a preference for one method over the other.

Clinical trial registration

Netherlands Trial Register, NL7077 (https://www.trialregister.nl/trial/7077).

Registration of phase 3 crossover trials on ClinicalTrials.gov

BACKGROUND

In a randomized crossover trial, each participant is randomized to a sequence of treatments and treatment effect is estimated based on within-individual difference because each participant serves as his/her own control. This feature makes the design and reporting of randomized crossover trials different from that of parallel trials. Our objective was to characterize phase 3 crossover trials with results reported on ClinicalTrials.gov and identify issues and best practices for reporting.

METHODS

We searched ClinicalTrials.gov for phase 3 randomized crossover trials that provided results, registered at least one primary outcome, and included at least one link to a results publication in the record by August 6, 2019. Two reviewers independently assessed the eligibility and extracted information from each record into an electronic form developed and maintained in the Systematic Review Data Repository.

RESULTS

Of the 124 crossover trials analyzed, two thirds were a simple "Intervention A then B" or "Intervention B then A" (AB|BA) design. Most trials (78%, 97/124) provided enough information to understand the participant flow throughout the trial. Baseline characteristics were most often reported for all participants as a single group (52%, 65/124). Primary outcomes and adverse events were most commonly reported "per intervention" (85%, 105/124, and 80%, 99/124, respectively).

CONCLUSIONS

The registration and reporting of randomized crossover trials must account for the paired nature of the design. Our observations and recommendations informed the development of guidelines for good reporting practices in the registration and reporting of randomized crossover trials.