Outcome domains and pain outcome measures in randomized controlled trials of interventions for postoperative pain in children and adolescents

Uptake of the core outcome set on polycystic ovary syndrome before and after its publication

STUDY QUESTION

Does the core outcome set (COS) on polycystic ovary syndrome (PCOS) impact the selection of research outcomes?

SUMMARY ANSWER

Following the publication of the COS on PCOS, an increasing number of trials are reporting both the generic domain and body mass index; however, the uptake of this COS has not been as extensive as expected.

WHAT IS KNOWN ALREADY

The COS on PCOS included 33 core outcomes in the following seven domains: the generic (3), metabolic (8), reproductive (7), pregnancy (10), psychological (3), oncological (1), and long-term (1). This was done to improve consistency in outcome selection and definition. However, thus far, no studies have investigated the effectiveness of this COS in the above-mentioned tasks.

STUDY DESIGN, SIZE, DURATION

A methodological study based on the trial registries, including 395 eligible clinical trials registered between 1 January 2018 and 21 September 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1258 registered clinical studies on PCOS were retrieved from the World Health Organization International Clinical Trials Registry Platform. Of those, 395 were selected according to the inclusion and exclusion criteria, and divided into two groups based on the publication date of the COS on PCOS (4 February 2020): pre-publication and post-publication. The practical uptake of this COS was explored after data collation, assessment, comparison of the uptake of core outcomes or domains before and after the publication of this COS, and correlation analysis between the domains.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 26 out of 33 core outcomes and five out of seven domains reported in the 395 trials. The highest uptake was observed for the reproductive domain and the reproductive hormonal profile (63.0% and 38.7%, respectively). After the publication of the COS on PCOS, the uptake of the generic domain and body mass index increased from 24.1% to 35.8% (P = 0.011) and 17.8% to 26.5% (P = 0.039), respectively. The total number of reported core outcomes in the generic domain met statistical significance (P = 0.012). Moreover, multivariable analyses still supported the above finding in the generic domain. Correlation analysis showed that most of the domains were positively correlated with each other. However, the pregnancy domain was negatively correlated with the metabolic domain. Reasons responsible for the unsatisfactory uptake may be the absence of specific definitions of core outcomes, as well as the lack of awareness among researchers regarding this COS.

LIMITATIONS, REASONS FOR CAUTION

Due to the lack of standardized definition of outcomes, it was difficult to avoid some subjectivity in the process of consistency assessment.

WIDER IMPLICATIONS OF THE FINDINGS

Two years after its publication, there was no substantial improvement in the uptake of the COS on PCOS. This suggests that this COS may require further revision, refinement, and promotion to improve the comparability of PCOS studies.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by Beijing Municipal Health Science and Technology Achievements and Appropriate Technology Promotion Project (BHTPP2022069), and the special fund of Beijing Key Clinical Specialty Construction Project. The authors do not have conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Consensus core outcome rating for the Japanese neonatal pain guidelines

Introduction

The Japanese Neonatal Pain Guidelines Committee, led by the Japan Academy of Neonatal Nursing, uses the Grading of Recommendations, Assessment, Development, and Evaluation Working Group method to evaluate the quality of evidence and the strength of treatment recommendations. Ratings on the importance of outcomes related to neonatal pain have not been reported. This study aimed to reach a consensus on the importance of outcomes through a guideline panel composed of doctors, nurses, a nurse practitioner, a physical therapist, and families to ensure consistency in systematic reviews of neonatal pain and future revisions to the guidelines.

Methods

A total of 26 professionals, including 21 medical personnel from clinical settings and academia and 5 parents from five family associations, participated in 3-stage eDelphi rounds.

Results

The literature review and discussion identified 75 outcomes that were included in round one. The participants proposed three additional outcomes: 78 outcomes were scored in rounds two and three. Round three scores showed different stakeholder groups in terms of priority outcomes. Seventeen outcomes were included in the final core outcome and were considered critical for decision-making.

Conclusion

Core outcomes of the development of neonatal pain guidelines in Japan were identified. The assessment process of importance from this study highlights the difference in the perspectives of medical providers and parents on neonatal pain, thus, involving parents in the assessment and as the spokesperson for the infant admitted to the neonatal intensive care unit is important for a more inclusive evaluation of pain prevention and management.

Safety and efficacy of esketamine for postoperative analgesia in pediatric patients with hypospadias

Objective

To explore the safety and efficacy of the combination of continuous intravenous infusion of esketamine with sacral block for postoperative analgesia in pediatric patients undergoing surgery for hypospadias

Methods

Pediatric patients (n = 77) undergoing surgery for hypospadias were randomized into two groups: a hydromorphone group (H group, initial dose, 0.02 mg/kg; maintenance dose, 0.01 mg/kg/h) or an esketamine group (E group, initial dose, 0.3 mg/kg; maintenance dose 0.15 mg/kg/h). Caudal epidural block involved injection of 0.2% ropivacaine 1 ml/kg through the sacral hiatus. Age, weight, grade of hypospadias, intraoperative blood loss, operative time, and awaking time of patients were recorded. The Face, Legs, Activity, Cry and Consolability (FLACC) scale and Ramsay sedation scores were recorded when leaving the PACU (0 h) and at postoperative 2, 6, 12, 24, 36, and 48 h. The Pediatric Anesthesia Emergence Delirium Scale (PAED), incidence of hypotension, respiratory depression, nausea and vomiting and pruritus, and the time to first bowel movement after surgery were recorded.

Results

There were no significant differences in demographic and clinical characteristics between the H group and the E group. There were no significant differences in FLACC scores at postoperative 0, 2, 6, 12, 24, 36, and 48 h in intra-group and inter-group comparisons. There were no significant differences in Ramsay sedation scores at postoperative 0, 2, 6, 12, 24, 36, and 48 h in the intra-group comparisons. Ramsay sedation scores were significantly lower at postoperative 2, 12, and 36 h in the H group compared to the E group. There were no significant differences in the PAED scale or incidence of nausea and vomiting or pruritus between the H group and the E group. The incidence of hypotension and respiratory depression was significantly lower, and the time to first bowel movement was significantly shorter in the E group compared to the H group. Urinary tryptophan, 5-hydroxytryptamine and substance P levels were significantly lower but arginine was significantly higher in the E group compared to the H group.

Conclusions

The combination of continuous intravenous infusion of esketamine with sacral block provided safe and effective postoperative analgesia for pediatric patients undergoing surgery for hypospadias.

Trial registration

Chinese Clinical Trial Register ChiCTR2200066967. Clinical trial registry URL: http://www.chictr.org.cn/edit.aspx?pid=185042&htm=4

[Perioperative Pain Management in Children]

Acute pain therapy in children is highly complex. Already preoperatively, the course for a successful therapy is set in the interaction with the child and parents. The goal of the treatment is a satisfied child. This means the use of empathy and therapy planning aimed at a balance between effect and side effect and functionality. Modern concepts are opioid-sparing and procedure-specific. Regional anaesthesia plays a major role, among other things due to excellent safety data. Knowledge of age- and block-specific local anaesthetic dosages is essential. Little is known about pharmacodynamic data of analgesics in children. Although knowledge about pharmacokinetic characteristics is increasing, off-label use of analgesics is inevitable. International databases such as the Kinderformularium provide up-to-date information. When using opioids, rules for safe handling must be followed both in terms of use and prescribing. Non-opioids and adjuvants - individually or in combination - have an established place in perioperative pain management. Non-pharmacological interventions can reduce anxiety and pain. Anxiety is one of the risk factors for chronic postsurgical pain.

Review finds core outcome set uptake in new studies and systematic reviews needs improvement

OBJECTIVE

To review evidence about the uptake of core outcome sets (COS). A COS is an agreed standardized set of outcomes that should be measured and reported, as a minimum, in all clinical trials in a specific area of health or health care.

STUDY DESIGN AND SETTING

This article provides an analysis of what is known about the uptake of COS in research. Similarities between COS and outcomes recommended by stakeholders in the evidence ecosystem is reviewed, and actions taken by them to facilitate COS uptake described.

RESULTS

COS uptake is low in most research areas. Common facilitators relate to trialist awareness and understanding. Common barriers were not including in the development process all specialties who might use the COS, and the lack of recommendations for how to measure the outcomes. Increasingly, COS developers are considering strategies for promoting uptake earlier in the process, including actions beyond traditional dissemination approaches. Overlap between COS and outcomes in regulatory documents and health technology assessments is good. An increasing number and variety of organisations are recommending COS be considered.

CONCLUSION

We suggest actions for various stakeholders for improving COS uptake. Research is needed to assess the impact of these actions to identify effective evidence-based strategies.

Recommendations from Cochrane reviews for improving future trials on anesthesia and pain: a meta-research study

Background: Cochrane systematic reviews (CSRs) have a section 'Implications for research' where authors make suggestions for improving future research. The authors of the present study assessed the prevalence and time dynamics of different recommendations in the CSRs about anesthesia and pain. Methods: The authors included all CSRs published by the Cochrane Anaesthesia Group and Cochrane Pain and Palliative Care Group before 17 July 2020. The authors analyzed recommendations for improving future research listed in the 'Implications for research' section of these CSRs and categorized recommendations for improvements. Results: They analyzed 370 reviews. Four categories of recommendations were present in more than 40% of the reviews. Most reviews recommended a larger sample size and better outcome choice, study design and choice of future intervention. These recommendations gradually increased in frequency in the Cochrane Pain and Palliative Care Group and mainly decreased in the Cochrane Anaesthesia Group. Conclusion: Recommendations from CSRs offer useful advice for trialists designing new trials.

In-depth qualitative interviews identified barriers and facilitators that influenced chief investigators' use of core outcome sets in randomised controlled trials

OBJECTIVE

This study aimed to investigate barriers and facilitators to core outcome set (COS) uptake in randomised controlled trials to inform the first steps in developing interventions to improve the uptake of COS.

STUDY DESIGN AND SETTING

Semi-structured qualitative interviews with a purposive sample of UK chief investigators were audio-recorded, transcribed and analysed thematically. Where appropriate, barriers and facilitators were mapped to components of behaviour informed by the COM-B model of behaviour.

RESULTS

Thirteen chief investigators were interviewed. Facilitators to uptake included: the behaviour of investigators, for example, their awareness and understanding of COS; and the wider research system, for example, recommendations to use COS from funders and journals. Barriers to uptake included: the perceived characteristics of COS, for example, increasing patient burden and recommendations becoming outdated; and the COS development process, for example, not including all specialties who will use the COS.

CONCLUSIONS

Based on the barriers and facilitators identified, recommendations to improve COS uptake include ensuring engagement with the research community who will use the COS, involving patients in the development of COS and ensuring COS remain up to date.

Researchers' choice of pain scales in trials of children undergoing surgery: A cross-sectional analysis of systematically searched randomized controlled trials and survey of authors

BACKGROUND

Many pain scales are used post-operatively in pediatric trials, making the comparison of trials, and the pooling of data for meta-analyses difficult. The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) statement, published in 2008, attempted to address this issue. We aimed to investigate the reasons for authors' choice of pain scales and the potential impact of PedIMMPACT.

METHODS

We performed a cross-sectional analysis of systematically searched randomized controlled trials testing tramadol in children (up to 16 years) undergoing surgery, published between 2000 and 2020 (9 years prior to and 12 years following the publication of PedIMMPACT).

RESULTS

Among 76 trials (6211 children), 49 unique pain scales were used. The choice of the scales was explained in 18 trials (24%); in 13 of them, authors at least partly justified their choice by the fact that the pain scale was validated. In 52 trials (68%), the pain scales were referenced, with a total of 59 unique references, most often to prior studies using the same scale (36%) or to studies validating the chosen scale (31%). Twenty-three trials (30%) provided no explanation nor reference. One single trial referenced PedIMMPACT. There was no evidence of a change in the choice of pain scales after the publication of PedIMMPACT.

CONCLUSIONS

A large variety of pain scales are still used in pediatric post-operative pain trials 12 years after the publication of PedIMMPACT. Only a minority of trials provided an explanation for their choice of pain scale. The reasons given most often included that the scale was validated or it was justified by a reference to a prior study using that scale. The impact of the publication of the PedIMMPACT seems limited. The ethics of the ongoing usage of large numbers of pain scales in pediatric pain trials must be challenged.

A decade later, there are still major issues to be addressed in paediatric anaesthesia

PURPOSE OF REVIEW

Despite real advances in paediatric anaesthesia management, such as a growing awareness of the relevance of anaesthesia conduct as well as of the lack of evidence for neurotoxicity of anaesthetic agents, it must be said that there are still important questions in our specialty that remain unanswered. Standardization and harmonization of airway management, analgesia techniques and outcome measures are the important issues we are facing at the beginning of this decade.

RECENT FINDINGS

Major improvements in airway management of neonates and infants resulted from the introduction of videolaryngoscopes and the systematic use of nasal oxygenation during endotracheal intubation. Similarly, the increasing popularity of dexmedetomidine has led to the generalization of its use, which, considering that it may produce undesirable effects, poses a challenge for the future. Moreover, recent systematic reviews have confirmed a lack of evidence for the efficacy of many techniques used in clinical practice.

SUMMARY

The shift in research from the neurotoxicity of anaesthetic agents to factors related to anaesthetic conduct are discussed. Examples for an improvement in anaesthesia management are highlighted with advocacy for including these evidence-based findings in routine clinical practice. Finally, the impact of using clinically relevant age-related and patient-centred perioperative outcomes is essential for comparing and/or interpreting the safety and efficacy of anaesthesia and analgesia management in children.

Wearable Devices: Current Status and Opportunities in Pain Assessment and Management

INTRODUCTION

We investigated the possibilities and opportunities for using wearable devices that measure physical activity and physiometric signals in conjunction with ecological momentary assessment (EMA) data to improve the assessment and treatment of pain.

METHODS

We considered studies with cross-sectional and longitudinal designs as well as interventional or observational studies correlating pain scores with measures derived from wearable devices. A search was also performed on studies that investigated physical activity and physiometric signals among patients with pain.

RESULTS

Few studies have assessed the possibility of incorporating wearable devices as objective tools for contextualizing pain and physical function in free-living environments. Of the studies that have been conducted, most focus solely on physical activity and functional outcomes as measured by a wearable accelerometer. Several studies report promising correlations between pain scores and signals derived from wearable devices, objectively measured physical activity, and physical function. In addition, there is a known association between physiologic signals that can be measured by wearable devices and pain, though studies using wearable devices to measure these signals and associate them with pain in free-living environments are limited.

CONCLUSION

There exists a great opportunity to study the complex interplay between physiometric signals, physical function, and pain in a real-time fashion in free-living environments. The literature supports the hypothesis that wearable devices can be used to develop reproducible biosignals that correlate with pain. The combination of wearable devices and EMA will likely lead to the development of clinically meaningful endpoints that will transform how we understand and treat pain patients.

A systematic review finds Core Outcome Set uptake varies widely across different areas of health

OBJECTIVE

The aim of our review was to bring together studies that had assessed the uptake of core outcome sets (COS) to explore the level of uptake across different COS and areas of health.

STUDY DESIGN AND SETTING

We examined the citations of 337 COS reports to identify studies that had assessed the uptake of a particular COS in randomized controlled trials (RCTs) or systematic reviews (SRs).

RESULTS

We identified 24 studies that had assessed uptake in RCTs and two studies that had assessed uptake in SRs. The studies covered a total of 17/337 (5%) COS. Uptake rates reported for RCTs varied from 0% of RCTs (gout) to 82% RCTs (rheumatoid arthritis) measuring the full COS. Studies that assessed uptake of individual core outcomes showed a wide variation in uptake between the outcomes. Suggested barriers to uptake included lack of validated measures, lack of patient and other key stakeholder involvement in COS development, and lack of awareness of the COS.

CONCLUSIONS

Few studies have been undertaken to assess the uptake of COS in RCTs and SRs. Further studies are needed to assess whether COS have been implemented across a wider range of disease categories and to explore the barriers and facilitators to COS uptake.

Pain assessment in clinical trials: a narrative review

Pain is a symptom measured in many clinical trials. For pain as an outcome domain, trialists need to choose adequate outcome measure(s), as there are myriad outcome measures for pain to choose from. To ensure consistency and uniformity in clinical trials and systematic reviews, core outcome sets (COS) have been defined; COS includes a predefined minimal list of core outcomes that should be measured within a trial, to ensure their consistency and comparability. COS is defined via consensus procedure, which includes relevant stakeholders such as experts from a specific field and patients. Along with outcomes, outcome measures for each outcome need to be defined to make sure that the outcomes will be measured consistently and uniformly. Hereby we reviewed studies that have examined use of recommended core outcome domains and outcome measures in clinical trials that would be expected to measure pain. Despite the existence of COS and defined core outcome measures (COMs), multiple studies have shown that these are not necessarily used in clinical trials, or in the relevant systematic reviews, which further increases heterogeneity of existing evidence, hinders evidence synthesis and trial comparability, and assessment of comparative effectiveness of interventions. Trialists are encouraged to use COS and COMs when designing clinical trials. Research community is encouraged to design interventions that will help with identifying barriers for using COS and COMs and interventions to foster their uptake. Use of consistent pain outcomes and pain outcome measures is in the interest of patients, research community, healthcare workers and decision-makers. For clinical conditions for which there are no COS and COMs, efforts to design them would be beneficial.

Bringing It All Together: A Review of the Challenges in Measuring Children's Satisfaction as a Key Component of Acute Pain Management

In 2008, the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) published a consensus statement that recognized the dearth of research surrounding the topic of children’s satisfaction with acute pain management. This review of published literature will summarize what is known about the topic of children’s satisfaction with pain management, identify current gaps in the knowledge, and provide direction for future research in this critical area. Including children in the decision-making process as soon as they are developmentally able is a concept that is the fundamental basis for seeking assent and more active roles within healthcare decisions for children. It is the responsibility of adults to provide them with increasing opportunities for self-evaluation and more independent management of their healthcare, encouraging the development of children into adults. As clinicians and researchers, it is our prerogative to support the maturation of children by building effective methods to communicate their satisfaction with acute pain treatment and healthcare. Children’s satisfaction with acute pain management is not well studied and further research is needed for the development of inclusive, developmentally appropriate measures of satisfaction for our pediatric patients.

Overall bias methods and their use in sensitivity analysis of Cochrane reviews were not consistent

OBJECTIVE

The objective of the study was to analyze methods of assessing "overall bias" in Cochrane reviews of interventions published in the Cochrane Database of Systematic Reviews and sensitivity analyses related to overall risk of bias (RoB).

STUDY DESIGN AND SETTING

From Cochrane reviews published within 3 years, from July 2015 to June 2018, we extracted data regarding methods of judging overall bias for a single trial, as well as details regarding methods used in frequency of RoB in sensitivity analyses.

RESULTS

Of the 1,452 analyzed Cochrane reviews, 409 mentioned assessment of overall RoB on a study level. In 107 reviews, authors clearly specified key domains that determined the overall RoB, whereas in the remaining reviews, assessment of overall bias was not in line with the Cochrane Handbook. Among 268 Cochrane reviews that had any RoB-related sensitivity analysis, in 56 (21%) reviews, the authors reported a significant change for at least one outcome compared with the initial analysis.

CONCLUSION

Highly heterogeneous approaches to summarizing overall RoB on a study level and using RoB for sensitivity analyses may yield inconsistent and incomparable results across Cochrane reviews.

The Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ): Development and Initial Psychometric Evaluation of a Brief and Comprehensive Measure of Pain and Pain Outcomes in Hospitalized Youth

Pediatric pain assessment in the hospital traditionally involves the patient's self-report of pain intensity using a numeric rating scale, which does not capture the complexity of the pain experience. No valid, comprehensive measure of pain in hospitalized youth exists. This study was designed to develop and conduct initial psychometric testing of the Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ), a comprehensive patient-reported measure of pain and pain outcomes in hospitalized youth. A multidisciplinary group of pediatric pain researchers and clinicians collaborated to adapt the adult APS-POQ Revised to pediatrics, including a patient-report and parent proxy version. The adapted measures were administered to 218 pediatric inpatients (age M = 13.4 years, 56% female) and 214 of their parents (80% mothers) at 4 US children's hospitals. The measure was feasible to administer within the inpatient setting and was acceptable and understandable to pediatric patients and their parents. Internal consistency was adequate for both patient-report and parent proxy (α = 0.77). Confirmatory factor analysis supported the following 6 domains, consistent with the adult measure: pain intensity, functional interference, emotional response, side effects, perceptions of care, and usual pain. Additional research is needed to further support the reliability and validity of this measure in diverse clinical populations. PERSPECTIVE: To reduce the impact of pain on hospitalized youth, pediatric pain assessment must move beyond ratings of pain intensity. The Pediatric APS-POQ provides a brief but comprehensive assessment of pain and pain outcomes in hospitalized children and adolescents, which will allow for greater individualization in hospital-based pain management and quality improvement purposes.