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Ramanan M, Kumar A, Billot L, Myburgh J, Venkatesh B. Recruitment characteristics of randomised trials in critical care: A systematic review. Clin Trials 2022; 19:673-680. [PMID: 36068946 DOI: 10.1177/17407745221123248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS To summarise the temporal trends of recruitment and methodological characteristics of critical care randomised controlled trials with the primary outcome of mortality. METHODS PubMed was searched for articles meeting inclusion and exclusion criteria. Randomised controlled trials, with primary outcome of mortality, of adult and paediatric critical care patients treated in an intensive care unit, were included. Neonatal intensive care unit trials, non-English publications and conference proceedings or abstracts without full-length publications were excluded. Duplicate literature search, article selection and quality assessment were performed by two reviewers with disputes resolved through discussion. Data were extracted into a custom-designed Research Electronic Data Capture database. RESULTS The search identified 67,199 records of which 230 were included. The annual number of critical care randomised controlled trials published increased gradually over a 30-year period from 0 in 1990 to 19 in 2014 with stabilisation at 8-11 between 2015 and 2020. Twenty-seven percent of randomised controlled trials were low risk in all categories using the Cochrane Risk of Bias tool. Methodological characteristics such as registration on clinical trials registries and data safety monitoring committee presence significantly (p < 0.001) increased over time. The median recruitment was 376 patients (interquartile range 125-895) with significant increase (p = 0.002) from 62 (interquartile range: 33-486) in 1991 to 725 (interquartile range: 537-2600) in 2020. This was accompanied by an increase in recruitment times. Thus overall, recruitment rates did not increase. Early cessation occurred in 23% (54/230) of randomised controlled trials with no temporal trend. CONCLUSION The number, size and some methodological qualities of critical randomised controlled trials with primary outcome of mortality have increased over time, but rates of recruitment and early cessation have been unchanged.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Meadowbrook, QLD, Australia
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Balasubramanian Venkatesh
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,Intensive Care Unit, Wesley Hospital, Auchenflower, QLD, Australia
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Buchtele N, Schwameis M, Roth D, Schwameis F, Kraft F, Ullrich R, Mühlbacher J, Laggner R, Gamper G, Semmler G, Schoergenhofer C, Staudinger T, Herkner H. Applicability of Vasopressor Trials in Adult Critical Care: A Prospective Multicentre Meta-Epidemiologic Cohort Study. Clin Epidemiol 2022; 14:1087-1098. [PMID: 36204153 PMCID: PMC9531614 DOI: 10.2147/clep.s372340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/30/2022] [Indexed: 12/15/2022] Open
Abstract
Objective To assess the applicability of evidence from landmark randomized controlled trials (RCTs) of vasopressor treatment in critically ill adults. Study Design and Setting This prospective, multi-center cohort study was conducted at five medical and surgical intensive care units at three tertiary care centers. Consecutive cases of newly initiated vasopressor treatment were included. The primary end point was the proportion of patients (≥18 years) who met the eligibility criteria of 25 RCTs of vasopressor therapy in critically ill adults included in the most recent Cochrane review. Multilevel Poisson regression was used to estimate the eligibility proportions with 95% confidence intervals for each trial. Secondary end points included the eligibility criteria that contributed most to trial ineligibility, and the relationship between eligibility proportions and (i) the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) score, and (ii) the recruitment-to-screening ratio of each RCT. The PRECIS-2 score was used to assess the degree of pragmatism of each trial. Results Between January 1, 2017, and January 1, 2019, a total of 1189 cases of newly initiated vasopressor therapy were included. The median proportion of cases meeting eligibility criteria for all 25 RCTs ranged from 1.3% to 6.0%. The eligibility criteria contributing most to trial ineligibility were the exceedance of a specific norepinephrine dose, the presence of a particular shock type, and the drop below a particular blood pressure value. Eligibility proportions increased with the PRECIS-2 score but not with the recruitment-to-screening ratio of the trials. Conclusion The applicability of evidence from available trials on vasopressor treatment in critically ill adults to patients receiving vasopressors in daily practice is limited. Applicability increases with the degree of study pragmatism but is not reflected in a high recruitment-to-screening ratio. Our findings may help researchers design vasopressor trials and promote standardized assessment and reporting of the degree of pragmatism achieved.
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Affiliation(s)
- Nina Buchtele
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
- Correspondence: Michael Schwameis, Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria, Tel +43 1 40400 39560, Fax +43 1 40400 19650, Email
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Franz Schwameis
- Department of Anaesthesiology and Intensive Care Medicine, Landesklinikum Baden, Vienna, Austria
| | - Felix Kraft
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Jakob Mühlbacher
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Roberta Laggner
- Department of Orthopaedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Gunnar Gamper
- Department of Cardiology, Universitätsklinikum Sankt Pölten, Vienna, Austria
| | - Georg Semmler
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Ramanan M, Billot L, Rajbhandari D, Myburgh J, Venkatesh B. An evaluation of factors that may influence clinicians' decisions not to enroll eligible patients into randomized trials in critical care. PLoS One 2021; 16:e0255361. [PMID: 34314449 PMCID: PMC8315530 DOI: 10.1371/journal.pone.0255361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/14/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To determine the association between intensive care unit (ICU) characteristics and clinicians' decision to decline eligible patients for randomization into a multicentered pragmatic comparative-effectiveness controlled trial. METHODS Screening logs from the Adjunctive Glucocorticoid Therapy in Septic Shock Trial (ADRENAL) and site-level data from the College of Intensive Care Medicine and Australia New Zealand Intensive Care Society were examined. The effects of ICU characteristics such as tertiary academic status, research coordinator availability, number of admissions, and ICU affiliations on clinicians declining to randomize eligible patients were calculated using mixed effects logistic regression modelling. RESULTS There were 21,818 patients screened for inclusion in the ADRENAL trial at 69 sites across five countries, out of which 5,501 were eligible, 3,800 were randomized and 659 eligible patients were declined for randomization by the treating clinician. The proportion of eligible patients declined by clinicians at individual ICUs ranged from 0 to41%. In the multivariable model, none of the ICU characteristics were significantly associated with higher clinician decline rate. CONCLUSIONS Neither tertiary academic status, nor other site-level variables were significantly associated with increased rate of clinicians declining eligible patients.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Laurent Billot
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dorrilyn Rajbhandari
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
- Intensive Care Unit, Wesley Hospital, Auchenflower, Queensland, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Koelman DLH, Brouwer MC, Ter Horst L, Bijlsma MW, van der Ende A, van de Beek D. Pneumococcal meningitis in adults: a prospective nationwide cohort studY over a 20-year period. Clin Infect Dis 2021; 74:657-667. [PMID: 34036322 PMCID: PMC8886910 DOI: 10.1093/cid/ciab477] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Indexed: 11/12/2022] Open
Abstract
Background The epidemiology and treatment of pneumococcal meningitis has changed with the implementation of conjugate vaccines and the introduction of adjunctive dexamethasone therapy. Methods We analyzed episodes of community-acquired pneumococcal meningitis in adults (≥16 years) in the Netherlands, identified by the National Reference Laboratory for Bacterial Meningitis or treating physician between October 1, 1998, and April 1, 2002, and between January 1, 2006, and July 1, 2018. We studied incidence, pneumococcal serotypes, and clinical features. Predictors for unfavorable outcome (Glasgow Outcome Scale score 1–4) were identified in a multivariable logistic regression model. Two physicians independently categorized causes of death as neurological or systemic. Results There were 1816 episodes in 1783 patients. The incidence of 7- and 10−7-valent pneumococcal conjugate vaccine serotypes decreased (from 0.42 to 0.06, P = .001; from 0.12 to 0.03 episodes per 100 000 population per year, P = .014). Incidence of nonvaccine serotypes increased (from 0.45 to 0.68, P = .005). The use of adjunctive treatment with dexamethasone increased and was administered in 85% of patients in 2018. In-hospital death occurred in 363 episodes (20%) and unfavorable outcome in 772 episodes (43%). Delayed cerebral thrombosis occurred in 29 patients (2%), of whom 15 patients (52%) died. Adjunctive dexamethasone therapy was associated with favorable outcome (adjusted odds ratio 2.27, P < .001), individual pneumococcal serotypes were not. Conclusion Implementation of conjugate vaccines and adjunctive dexamethasone therapy have changed the incidence and outcome of pneumococcal meningitis in adults over the last two decades. Despite recent advances pneumococcal meningitis remains associated with a residual high rate of mortality and morbidity.
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Affiliation(s)
- Diederik L H Koelman
- Amsterdam UMC, University of Amsterdam, the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Amsterdam UMC, University of Amsterdam, the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands
| | - Liora Ter Horst
- Amsterdam UMC, University of Amsterdam, the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands
| | - Merijn W Bijlsma
- Amsterdam UMC, University of Amsterdam, the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands
| | - Arie van der Ende
- Department of Neurology, Amsterdam Neuroscience, the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Medical Microbiology and Infection Prevention and the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Amsterdam UMC, University of Amsterdam, the Netherlands Reference Laboratory for Bacterial Meningitis, Meibergdreef 9, Amsterdam, The Netherlands
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Lee M, Curley GF, Mustard M, Mazer CD. The Swan-Ganz Catheter Remains a Critically Important Component of Monitoring in Cardiovascular Critical Care. Can J Cardiol 2017; 33:142-147. [DOI: 10.1016/j.cjca.2016.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022] Open
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De Backer D, Vincent JL. Early goal-directed therapy: do we have a definitive answer? Intensive Care Med 2016; 42:1048-50. [PMID: 26951428 DOI: 10.1007/s00134-016-4295-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/24/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Rue Wayez 35, Braine L'Alleud, 1420, Brussels, Belgium.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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