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Kazdin AE. Drawing causal inferences from randomized controlled trials in psychotherapy research. Psychother Res 2023; 33:991-1003. [PMID: 36226476 DOI: 10.1080/10503307.2022.2130112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/20/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE Randomized control trials (RCTs) have played a critical role in psychotherapy research. This article discusses RCTs in the context of the criteria for drawing causal inferences in psychotherapy and intervention research more generally. The article also highlights underused variations of RCTs and how they not only establish causal relations but also address critical questions that can improve our intervention portfolio and patient care. CONCLUSION Random assignment is discussed in terms of what it can and cannot do in relation to drawing conclusions about the effects of interventions. Finally, RCTs are examined in the context of multiple questions that can guide therapy research, improve patient care, and develop treatments that reach people in need of psychological services.
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Affiliation(s)
- Alan E Kazdin
- Department of Psychology, Yale University, New Haven, CT, USA
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2
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Szekeres M, MacDermid JC. Online learning versus workshops: a rank minimized trial comparing the effect of two knowledge translation strategies designed to alter knowledge, readiness to change, and self-efficacy with respect to rehabilitation outcome measures. Disabil Rehabil 2021; 44:6531-6538. [PMID: 34455882 DOI: 10.1080/09638288.2021.1965227] [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: 10/20/2022]
Abstract
PURPOSE Traditional face-to-face learning is often replaced by virtual learning because it can be more feasible and cost-effective, and more recently due to the need for social distancing. The objective was to evaluate the effectiveness of two innovative knowledge translation (KT) interventions; in-person stakeholder-hosted, interactive, problem-based seminars (SHIPS) versus online problem-based tutorials (e-PBL) in changing knowledge, readiness to change, and self-efficacy with respect to the use of rehabilitation outcome measures. METHODS Physical and occupational therapists (n = 124) were recruited from four sites across Canada to participate in either an e-PBL or SHIPS. Evaluations of KT impact measured knowledge, self-efficacy to implement outcome measures in practice, and readiness to change. RESULTS There were 112 participants who completed the study. Following the intervention, the mean knowledge scores for both groups improved, but there was greater improvement in participants who completed SHIPS. For self-efficacy and readiness to change, there was no significant difference between groups six months following the interventions. E-PBL was as good as a SHIPS for improving and retaining self-efficacy and readiness to change. CONCLUSIONS Knowledge improved more with workshops than online delivery, while improvements in self-efficacy and readiness to change improved similarly regardless of delivery.Implications for RehabilitationThis study compared the relative efficacy of internet and workshop-based education, focusing specifically on the use of outcome measures in physical and occupational therapy practice.Improvements in the self-efficacy of rehabilitation professionals with respect to outcome measure use had lasting effects regardless of KT intervention type, as it was retained six months following the intervention.Results from this study show that online interventions may be as effective as face-to-face workshops for improving readiness to change and self-efficacy for using outcome measures in practice by rehabilitation professionals.This is valuable information given the recent global pandemic, the need for social distancing, and the potential for learning interventions to focus within the online environment in the future.
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Affiliation(s)
- Mike Szekeres
- Lawson Health Research Institute, London, Canada.,The Roth McFarlane Hand and Upper Limb Centre, London, Canada
| | - Joy C MacDermid
- Health and Rehabilitation Sciences, Western University, London, Canada.,The Roth McFarlane Hand and Upper Limb Centre, London, Canada
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Pool D, Valentine J, Taylor NF, Bear N, Elliott C. Locomotor and robotic assistive gait training for children with cerebral palsy. Dev Med Child Neurol 2021; 63:328-335. [PMID: 33225442 DOI: 10.1111/dmcn.14746] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 12/20/2022]
Abstract
AIM To determine if robotic assisted gait training (RAGT) using surface muscle electrical stimulation and locomotor training enhances mobility outcomes when compared to locomotor training alone in children with cerebral palsy (CP). METHOD Forty children (18 females, 22 males; mean age 8y 1mo, SD 2y 1mo; range 5y 1mo-12y 11mo) with CP in Gross Motor Function Classification System levels (GMFCS) III, IV, and V were randomly assigned to the RAGT and locomotor training (RAGT+LT) group or locomotor training only group (dosage for both: three 1-hour sessions a week for 6 weeks). Outcomes were assessed at baseline T1 (week 0), post-treatment T2 (week 6), and retention T3 (week 26). The primary outcome measure was the Goal Attainment Scale. Secondary outcome measures included the 10-metre walk test, children's functional independence measure mobility and self-care domain, the Canadian Occupational Performance Measure, and the Gross Motor Function Measure. RESULTS There were no significant differences between the groups for both the primary and secondary outcome measures. All participants completed the intervention in their original group allocation. There were no reported adverse events. INTERPRETATION The addition of RAGT to locomotor training does not significantly improve motor outcomes in children with CP in GMFCS levels III, IV, and V. Future studies could investigate health and well-being outcomes after locomotor training. WHAT THIS PAPER ADDS Marginally ambulant and non-ambulant children with cerebral palsy can participate in locomotor training. Robotic assisted gait training when added to locomotor training does not appear to be any more effective than locomotor training alone.
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Affiliation(s)
- Dayna Pool
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Western Australia, Australia.,Kids Rehab, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jane Valentine
- Kids Rehab, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Nicholas F Taylor
- School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Natasha Bear
- Kids Rehab, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Western Australia, Australia.,Kids Rehab, Perth Children's Hospital, Perth, Western Australia, Australia.,Telethon Kids Institute, Perth, Western Australia, Australia
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Swinnen N, Vandenbulcke M, Vancampfort D. Exergames in people with major neurocognitive disorder: a systematic review. Disabil Rehabil Assist Technol 2020; 17:376-389. [PMID: 32697614 DOI: 10.1080/17483107.2020.1785566] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To systematically evaluate the efficacy of exergames in individuals with major neurocognitive disorder. MATERIALS AND METHODS PubMed, EMBASE and PEDro were systematically searched from inception until October 2019 for randomised and clinical controlled trials. Methodological quality of the trials was assessed with the PEDro rating scale or Risk of Bias in Nonrandomised Studies of Interventions-I (ROBINS-I), when appropriate. Grading of Recommendations Assessments, Development and Evaluation (GRADE) was used to assess the overall quality of the evidence. RESULTS Eight trials, all of moderate to high methodological quality (i.e., PEDro score of 6 or higher or a Robins-I moderate quality score) were included. The overall quality of evidence was moderate to high according to the GRADE criteria. Improvements in gait, mobility and balance and beneficial effects on activities of daily living performance, cognitive function, fear of falls, quality of life and mood following exergaming were reported. Heterogeneity in outcome measures, intervention characteristics and included participants precluded a meta-analysis. CONCLUSIONS The current literature is of moderate to high quality and demonstrates that exergames have a wide range of physical and mental benefits in people with major neurocognitive disorder. More controlled trials are however needed to confirm the existing evidence before exergames can be recommended in treatment guidelines for people with major neurocognitive disorder.Implications for rehabilitationExergames have many physical and mental benefits in people with major neurocognitive disorderExergaming can enhance gait, mobility and balance in people with major neurocognitive disorderEvidence for beneficial cognitive effects of exergaming is emerging.
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Affiliation(s)
- Nathalie Swinnen
- Faculty of Movement and Rehabilitation Sciences, KU Leuven, Leuven, Belgium.,University Psychiatric Center, KU Leuven, Kortenberg, Belgium
| | - Mathieu Vandenbulcke
- University Psychiatric Center, KU Leuven, Leuven, Belgium.,Research Group Psychiatry, University Psychiatric Center, KU Leuven, Leuven, Belgium
| | - Davy Vancampfort
- University Psychiatric Center, KU Leuven, Kortenberg, Belgium.,Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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Hilyard A, Kingsley J, Sommerfield D, Taylor S, Bear N, Gibson N. Feasibility of a Randomized Controlled Trial of Paediatric Interdisciplinary Pain Management Using Home-Based Telehealth. J Pain Res 2020; 13:897-908. [PMID: 32431538 PMCID: PMC7200248 DOI: 10.2147/jpr.s217022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 12/18/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Chronic pain is common in adolescents. Evidence-based guidelines recommend interdisciplinary treatment, but access is limited by geography. The development of hybrid programs utilizing both face-to-face and videoconference treatment may help overcome this. We developed a 7-week hybrid pediatric interdisciplinary pain program (Hybrid-PIPP) and wished to compare it to individual face-to-face sessions (Standard Care). Our objective was to test the feasibility of a protocol that used a matched pair un-blinded randomized controlled design to investigate the efficacy and cost-effectiveness of the Hybrid-PIPP compared to Standard Care. Patients and Methods Parent-adolescent dyads were recruited from tertiary pediatric clinics and matched by disability before randomization to minimize allocation bias. The adolescents (aged 11-17) had experienced primary pain for >3 months. Hybrid-PIPP involved 11 hrs of group therapy and 4 individual videoconference sessions. Standard care was provided by the same clinical team, using the same treatment model and similar intensity as the Hybrid-PIPP. The intention was to recruit participants for 3 Hybrid-PIPP groups with a comparison stream. Recruitment was ceased after 2 groups due to the high participant disability requiring more intensive intervention. Results Eighteen dyads were screened and 13 randomized (7 Hybrid-PIPP, 6 Standard Care, 2 unsuitable, 3 unallocated when the study was stopped). The study met a priori feasibility criteria for staff availability; recruitment rate; treatment completion; and data collection. Global satisfaction ratings were similar in both streams (SC median 7, range 5-9 and Hybrid-PIPP median 8.5, range 5-10). Challenges were identified in both streams. A future modified Hybrid-PIPP was considered acceptable if the intensity is increased to manage the high level of disability. Standard care was considered inefficient. No adverse events were reported. Conclusion The study determined that the protocol met a priori feasibility criteria, but to be practicable in a real world, health environment requires significant modifications. Registration ANZTR(ACTRN2614000489695).
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Affiliation(s)
- Anna Hilyard
- Complex Pain Service, Perth Children's Hospital, Perth, Western Australia, Australia.,Discipline of Psychology, College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia
| | - Julia Kingsley
- Complex Pain Service, Perth Children's Hospital, Perth, Western Australia, Australia
| | - David Sommerfield
- Complex Pain Service, Perth Children's Hospital, Perth, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Susan Taylor
- Complex Pain Service, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Occupational Therapy, Social Work and Speech Pathology, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Perth, Western Australia, Australia
| | - Noula Gibson
- Physiotherapy Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
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Lange S, Sauerland S, Lauterberg J, Windeler J. The Range and Scientific Value of Randomized Trials. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:635-640. [PMID: 29017690 DOI: 10.3238/arztebl.2017.0635] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 04/06/2017] [Accepted: 06/12/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The randomized, controlled trial (RCT) is the gold standard of scientific evidence for the attribution of clinical effects (benefits and harms) to medical interventions. Many different designs for RCTs have been developed in order to counter legitimate critical objections and to better adapt the trials to the continually changing challenges that face clinical research. METHODS The diversity and adaptability of randomized trial designs are presented and discussed on the basis of a selective literature review and specific illustrative examples. RESULTS A wide range of RCT designs enables adaptation to special research tasks and clinical framework conditions. These include (among others) crossover trials, n=1 trials, factorial RCT designs, and cluster-randomized trials. In addition, adaptive designs such as modern platform trials and pragmatic RCTs with simplified clinical questions and less severely restricted patient groups make broad recruitment of patients possible even in routine clinical practice. CONCLUSION Only the randomized allocation of subjects to the treatment and control groups, which is the defining property of RCTs, can adequately ensure that traits of the subjects which might disturb or bias a comparison of two or more medical interventions, will be evenly distributed across groups, regardless of whether these traits are known or unknown. The methodological variants and further elaborations of the RCT that are discussed here will help protect patients by enabling the assessment of the benefits and harms of medical methods and products on the basis of robust evidence even in the present era of rapid innovation.
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McLean B, Blakeman M, Carey L, Ward R, Novak I, Valentine J, Blair E, Taylor S, Bear N, Bynevelt M, Basc E, Rose S, Reid L, Pannek K, Angeli J, Harpster K, Elliott C. Discovering the sense of touch: protocol for a randomised controlled trial examining the efficacy of a somatosensory discrimination intervention for children with hemiplegic cerebral palsy. BMC Pediatr 2018; 18:252. [PMID: 30064388 PMCID: PMC6069953 DOI: 10.1186/s12887-018-1217-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 07/09/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Of children with hemiplegic cerebral palsy, 75% have impaired somatosensory function, which contributes to learned non-use of the affected upper limb. Currently, motor learning approaches are used to improve upper-limb motor skills in these children, but few studies have examined the effect of any intervention to ameliorate somatosensory impairments. Recently, Sense© training was piloted with a paediatric sample, seven children with hemiplegic cerebral palsy, demonstrating statistically and clinically significant change in limb position sense, goal performance and bimanual hand-use. This paper describes a protocol for a Randomised Controlled Trial of Sense© for Kids training, hypothesising that its receipt will improve somatosensory discrimination ability more than placebo (dose-matched Goal Directed Therapy via Home Program). Secondary hypotheses include that it will alter brain activation in somatosensory processing regions, white-matter characteristics of the thalamocortical tracts and improve bimanual function, activity and participation more than Goal Directed Training via Home Program. METHODS AND DESIGN This is a single blind, randomised matched-pair, placebo-controlled trial. Participants will be aged 6-15 years with a confirmed description of hemiplegic cerebral palsy and somatosensory discrimination impairment, as measured by the sense©_assess Kids. Participants will be randomly allocated to receive 3h a week for 6 weeks of either Sense© for Kids or Goal Directed Therapy via Home Program. Children will be matched on age and severity of somatosensory discrimination impairment. The primary outcome will be somatosensory discrimination ability, measured by sense©_assess Kids score. Secondary outcomes will include degree of brain activation in response to a somatosensory task measured by functional MRI, changes in the white matter of the thalamocortical tract measured by diffusion MRI, bimanual motor function, activity and participation. DISCUSSION This study will assess the efficacy of an intervention to increase somatosensory discrimination ability in children with cerebral palsy. It will explore clinically important questions about the efficacy of intervening in somatosensation impairment to improve bimanual motor function, compared with focusing on motor impairment directly, and whether focusing on motor impairment alone can affect somatosensory ability. TRIAL REGISTRATION This trial is registered with the Australian New Zealand Clinical Trials Registry, registration number: ACTRN12618000348257. World Health Organisation universal trial number: U1111-1210-1726.
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Affiliation(s)
- Belinda McLean
- School of Adolescent and Child Health, University of Western Australia, Perth, WA Australia
- Kids Rehab Department, Perth Children’s Hospital, Perth, WA Australia
| | - Misty Blakeman
- Kids Rehab Department, Perth Children’s Hospital, Perth, WA Australia
| | - Leeanne Carey
- Department of Community and Clinical Allied Health, School of Allied Health, La Trobe University, Melbourne, VIC Australia
- Neurorehabilitation and Recovery, Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC Australia
| | - Roslyn Ward
- School of Occupational Therapy and Social Work, Curtin University, Perth, WA Australia
| | - Iona Novak
- Cerebral Palsy Alliance, Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, NSW Australia
| | - Jane Valentine
- School of Adolescent and Child Health, University of Western Australia, Perth, WA Australia
- Kids Rehab Department, Perth Children’s Hospital, Perth, WA Australia
| | - Eve Blair
- Telethon Kids Institute, University of Western Australia, Perth, WA Australia
| | - Susan Taylor
- Kids Rehab Department, Perth Children’s Hospital, Perth, WA Australia
- School of Occupational Therapy and Social Work, Curtin University, Perth, WA Australia
| | - Natasha Bear
- Department of Clinical Research and Education, Child and Adolescent Health Services, Perth, WA Australia
| | - Michael Bynevelt
- Kids Rehab Department, Perth Children’s Hospital, Perth, WA Australia
- Sir Charles Gairdner Hospital, Perth, WA Australia
| | - Emma Basc
- Consumer Representative, Perth, WA Australia
| | - Stephen Rose
- Australian e-Health Research Centre, CSIRO, Brisbane, Queensland Australia
| | - Lee Reid
- Australian e-Health Research Centre, CSIRO, Brisbane, Queensland Australia
| | - Kerstin Pannek
- Australian e-Health Research Centre, CSIRO, Brisbane, Queensland Australia
| | - Jennifer Angeli
- School of Adolescent and Child Health, University of Western Australia, Perth, WA Australia
- Kids Rehab Department, Perth Children’s Hospital, Perth, WA Australia
| | - Karen Harpster
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio USA
| | - Catherine Elliott
- School of Occupational Therapy and Social Work, Curtin University, Perth, WA Australia
- Department of Clinical Research and Education, Child and Adolescent Health Services, Perth, WA Australia
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Glynne-Jones R, Adams R, Lopes A, Meadows H. Clinical endpoints in trials of chemoradiation for patients with anal cancer. Lancet Oncol 2017; 18:e218-e227. [PMID: 28368260 DOI: 10.1016/s1470-2045(17)30190-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/01/2016] [Accepted: 12/08/2016] [Indexed: 12/22/2022]
Abstract
This Review examines the reporting of endpoints in randomised controlled trials (RCTs) of radical chemoradiation for treatment of squamous cell carcinoma of the anus. The types, frequency, and definitions of clinical primary and secondary endpoints, and patient-reported outcome measures, reported in the methods and results sections of papers (and protocols, if available) were examined. Only six published RCTs comprising 2877 patients were identified. Primary outcome measures varied across the trials analysed: two used disease-free survival, one used progression-free survival, two used local failure, and one used colostomy-free survival. Secondary endpoints included overall survival, complete clinical response, quality of life, toxicity, and compliance. The definitions for primary and secondary endpoints were not consistent across trials, particularly for treatment failure (local, regional, and distant). We conclude that the quality of outcome reporting in RCTs of squamous cell carcinoma of the anus is inconsistent. A core set of outcomes, including clinical and patient-reported outcome measures with standardised definitions, is needed to improve the reporting of RCTs examining chemoradiation for treatment of patients with squamous cell carcinoma of the anus.
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Affiliation(s)
| | - Richard Adams
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
| | - Andre Lopes
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
| | - Helen Meadows
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
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Ward R, Reynolds JE, Bear N, Elliott C, Valentine J. What is the evidence for managing tone in young children with, or at risk of developing, cerebral palsy: a systematic review. Disabil Rehabil 2016; 39:619-630. [DOI: 10.3109/09638288.2016.1153162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Roslyn Ward
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jess E. Reynolds
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- School of Sport, Science, Exercise and Health, the University of Western Australia, Perth, Western Australia, Australia
| | - Natasha Bear
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth, Western Australia, Australia
- Department of Physiotherapy, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Department of Clinical Research, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Catherine Elliott
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- School of Occupational Therapy and Social Work, Curtin University, Western Australia, Australia
| | - Jane Valentine
- Department of Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
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Blake SF, Logan S, Humphreys G, Matthews J, Rogers M, Thompson‐Coon J, Wyatt K, Morris C. Sleep positioning systems for children with cerebral palsy. Cochrane Database Syst Rev 2015; 2015:CD009257. [PMID: 26524348 PMCID: PMC8761500 DOI: 10.1002/14651858.cd009257.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sleep positioning systems can be prescribed for children with cerebral palsy to help reduce or prevent hip migration, provide comfort to ease pain and/or improve sleep. As sleep disturbance is common in children with developmental disabilities, with impact on their carers' sleep, and as sleep positioning systems can be expensive, guidance is needed to support decisions as to their use. OBJECTIVES To determine whether commercially-available sleep positioning systems, compared with usual care, reduce or prevent hip migration in children with cerebral palsy. Any negative effect of sleep positioning systems on hip migration will be considered within this objective.Secondary objectives were to determine the effect of sleep positioning systems on: (1) number or frequency of hip problems; (2) sleep patterns and quality; (3) quality of life of the child and family; (4) pain; and (5) physical functioning. We also sought to identify any adverse effects from using sleep positioning systems. SEARCH METHODS In December 2014, we searched CENTRAL, Ovid MEDLINE, Embase, and 13 other databases. We also searched two trials registers. We applied no restrictions on date of publication, language, publication status or study design. We checked references and contacted manufacturers and authors for potentially relevant literature, and searched the internet using Google. SELECTION CRITERIA We included all randomised controlled trials (RCTs) evaluating whole body sleep positioning systems for children and adolescents (up to 18 years of age) with cerebral palsy. DATA COLLECTION AND ANALYSIS Two review authors independently screened reports retrieved from the search against pre-determined inclusion criteria and assessed the quality of eligible studies.Members of the public (parent carers of children with neurodisability) contributed to this review by suggesting the topic, refining the research objectives, interpreting the findings, and reviewing the plain language summary. MAIN RESULTS We did not identify any randomised controlled trials that evaluated the effectiveness of sleep positioning systems on hip migration.We did find two randomised cross-over trials that met the inclusion criteria in respect of secondary objectives relating to sleep quality and pain. Neither study reported any important difference between sleeping in sleep positioning systems and not for sleep patterns or sleep quality (two studies, 21 children, very low quality evidence) and pain (one study, 11 children, very low quality evidence). These were small studies with established users of sleep positioning systems and were judged to have high risk of bias.We found no eligible trials that explored the other secondary objectives (number or frequency of hip problems, quality of life of the child and family, physical functioning, and adverse effects). AUTHORS' CONCLUSIONS We found no randomised trials that evaluated the effectiveness of sleep positioning systems to reduce or prevent hip migration in children with cerebral palsy. Nor did we find any randomised trials that evaluated the effect of sleep positioning systems on the number or frequency of hip problems, quality of life of the child and family or on physical functioning.Limited data from two randomised trials, which evaluated the effectiveness of sleep positioning systems on sleep quality and pain for children with cerebral palsy, showed no significant differences in these aspects of health when children were using and not using a sleep positioning system.In order to inform clinical decision-making and the prescription of sleep positioning systems, more rigorous research is needed to determine effectiveness, cost-effectiveness, and the likelihood of adverse effects.
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Affiliation(s)
- Sharon F Blake
- University of Exeter Medical SchoolPeninsula Cerebra Research Unit (PenCRU)Room 008, Veysey BuildingSalmon Pool LaneExeterDevonUKEX2 4SG
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
| | - Stuart Logan
- University of Exeter Medical SchoolPeninsula Cerebra Research Unit (PenCRU)Room 008, Veysey BuildingSalmon Pool LaneExeterDevonUKEX2 4SG
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
| | - Ginny Humphreys
- Vranch House Clinical ServicesPinhoe RoadExeterEX4 8APUKDevon
| | - Justin Matthews
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
| | - Morwenna Rogers
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
| | - Joanna Thompson‐Coon
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
| | - Katrina Wyatt
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
| | - Christopher Morris
- University of Exeter Medical SchoolPeninsula Cerebra Research Unit (PenCRU)Room 008, Veysey BuildingSalmon Pool LaneExeterDevonUKEX2 4SG
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterUK
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Zeller T, Baumgartner I, Scheinert D, Brodmann M, Bosiers M, Micari A, Peeters P, Vermassen F, Landini M, Snead DB, Kent KC, Rocha-Singh KJ. Drug-eluting balloon versus standard balloon angioplasty for infrapopliteal arterial revascularization in critical limb ischemia: 12-month results from the IN.PACT DEEP randomized trial. J Am Coll Cardiol 2014; 64:1568-76. [PMID: 25301459 DOI: 10.1016/j.jacc.2014.06.1198] [Citation(s) in RCA: 280] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/24/2014] [Accepted: 06/24/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug-eluting balloons (DEB) may reduce infrapopliteal restenosis and reintervention rates versus percutaneous transluminal angioplasty (PTA) and improve wound healing/limb preservation. OBJECTIVES The goal of this clinical trial was to assess the efficacy and safety of IN.PACT Amphirion drug-eluting balloons (IA-DEB) compared to PTA for infrapopliteal arterial revascularization in patients with critical limb ischemia (CLI). METHODS Within a prospective, multicenter, randomized, controlled trial with independent clinical event adjudication and angiographic and wound core laboratories 358 CLI patients were randomized 2:1 to IA-DEB or PTA. The 2 coprimary efficacy endpoints through 12 months were clinically driven target lesion revascularization (CD-TLR) and late lumen loss (LLL). The primary safety endpoint through 6 months was a composite of all-cause mortality, major amputation, and CD-TLR. RESULTS Clinical characteristics were similar between the 2 groups. Significant baseline differences between the IA-DEB and PTA arms included mean lesion length (10.2 cm vs. 12.9 cm; p = 0.002), impaired inflow (40.7% vs. 28.8%; p = 0.035), and previous target limb revascularization (32.2% vs. 21.8%; p = 0.047). Primary efficacy results of IA-DEB versus PTA were CD-TLR of 9.2% versus 13.1% (p = 0.291) and LLL of 0.61 ± 0.78 mm versus 0.62 ± 0.78 mm (p = 0.950). Primary safety endpoints were 17.7% versus 15.8% (p = 0.021) and met the noninferiority hypothesis. A safety signal driven by major amputations through 12 months was observed in the IA-DEB arm versus the PTA arm (8.8% vs. 3.6%; p = 0.080). CONCLUSIONS In patients with CLI, IA-DEB had comparable efficacy to PTA. While primary safety was met, there was a trend towards an increased major amputation rate through 12 months compared to PTA. (Study of IN.PACT Amphirion™ Drug Eluting Balloon vs. Standard PTA for the Treatment of Below the Knee Critical Limb Ischemia [INPACT-DEEP]; NCT00941733).
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Iris Baumgartner
- Swiss Cardiovascular Center, Division of Angiology, University Hospital, Inselspital, Bern, Switzerland
| | - Dierk Scheinert
- Center of Vascular Medicine, Park Hospital Leipzig, Leipzig, Germany
| | | | - Marc Bosiers
- Department of Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium
| | - Antonio Micari
- Invasive Cardioangiology GVM Care and Research, Palermo, Italy
| | - Patrick Peeters
- Department of Cardiovascular & Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Frank Vermassen
- Department of Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Mario Landini
- Medtronic Endovascular Therapies, Santa Rosa, California
| | - David B Snead
- Medtronic Endovascular Therapies, Santa Rosa, California
| | - K Craig Kent
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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12
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Schuetz P, Blaser Yildirim PZ, Gloy VL, Briel M, Bally MR. Early nutritional therapy for malnourished or nutritionally at-risk adult medical inpatients. Cochrane Database Syst Rev 2014. [DOI: 10.1002/14651858.cd011096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Clark F, Pyatak EA, Carlson M, Blanche EI, Vigen C, Hay J, Mallinson T, Blanchard J, Unger JB, Garber SL, Diaz J, Florindez LI, Atkins M, Rubayi S, Azen SP. Implementing trials of complex interventions in community settings: the USC-Rancho Los Amigos pressure ulcer prevention study (PUPS). Clin Trials 2014; 11:218-29. [PMID: 24577972 PMCID: PMC3972348 DOI: 10.1177/1740774514521904] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects. PURPOSE We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury. METHODS Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes. RESULTS PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination. LIMITATIONS We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings. CONCLUSIONS Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.
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Affiliation(s)
- Florence Clark
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Elizabeth A. Pyatak
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Mike Carlson
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Erna Imperatore Blanche
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Cheryl Vigen
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Joel Hay
- Leonard Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Trudy Mallinson
- School of Medicine and Health Sciences, The University of George Washington, Washington, DC, USA
| | - Jeanine Blanchard
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Jennifer B. Unger
- Institute for Health Promotion and Disease Prevention Research, University of Southern California, Los Angeles, CA, USA
| | - Susan L. Garber
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Jesus Diaz
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Lucia I. Florindez
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
| | - Michal Atkins
- Pressure Ulcer Management Service, Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | - Salah Rubayi
- Pressure Ulcer Management Service, Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | - Stanley Paul Azen
- Division of Biostatistics, University of Southern California, Los Angeles, CA, USA
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Naumann-Winter F, Greb A, Borchmann P, Bohlius J, Engert A, Schnell R. First-line tandem high-dose chemotherapy and autologous stem cell transplantation versus single high-dose chemotherapy and autologous stem cell transplantation in multiple myeloma, a systematic review of controlled studies. Cochrane Database Syst Rev 2012; 10:CD004626. [PMID: 23076906 DOI: 10.1002/14651858.cd004626.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Several clinical studies have compared single with tandem (also called double) autologous stem cell transplantation (ASCT) as first-line treatment in patients with symptomatic multiple myeloma (MM), one of the leading indications for ASCT worldwide. OBJECTIVES The present Cochrane Review compares tandem autologous stem cell transplantation (TASCT) with single autologous stem cell transplantation (SASCT) as first-line treatment in patients with symptomatic MM with respect to overall survival (OS), event-free survival (EFS), quality of life (QoL) and treatment- or transplantation-related mortality. SEARCH METHODS We systematically identified controlled trials published between January 1995 and May 2011 in two bibliographic databases (MEDLINE and CENTRAL) and in clinical trial registries. SELECTION CRITERIA One researcher screened references for controlled trials to determine eligibility for the systematic review (SR) according to pre-specified inclusion and exclusion criteria, reflecting characteristics of disease and the interventions. We required a minimal set of details to be reported for observational studies for the studies to be included. DATA COLLECTION AND ANALYSIS We critically evaluated eligible trials with respect to quality of design and actual performance. One researcher extracted individual trial results, which were checked by another researcher. We recapitulated the results of the individual trials in a standardised way for the SR in order to allow a systematic assessment of potential sources of bias. MAIN RESULTS Overall, we identified 14 controlled studies. One registered randomised controlled trial (RCT) is still recruiting patients at the time of this review and no clinical results have been published. Two registered RCTs have remained unpublished despite their termination. Publications on one RCT had been retracted. We excluded five observational studies since neither patients nor treatment regimens were sufficiently characterised to allow an assessment of potential confounding by indication. We conducted a SR of study designs, definition of endpoints, treatment regimens and baseline characteristics of patients in the five included RCTs (two full-text publications, three conference presentations) enrolling1506 patients in total. Because we identified substantial clinical and methodological heterogeneity, we refrained from conducting a formal meta-analysis.While we included only previously untreated, symptomatic patients with MM the treatment regimens differed notably with respect to acute toxicity, between trials and also between study arms. Compared to state of the art treatment standards, the treatment regimens applied in all trials have to be considered as below standard from a contemporary perspective in at least one component.Three trials were likely to have the potential of being highly biased while two RCTs had a moderate potential for bias. The observed treatment effects in the set of included trials may have been influenced by a steep decrease in compliance with the second ASCT and the concomitant selection of patients. In addition, OS data were confounded by the treatment subsequent to first-line therapy.OS was statistically significantly improved in one trial only. While EFS was prolonged in four of the five trials, the median prolongation ranged between three to 12 months, with an uncertain direction of bias in the individual trials. QoL was not reported in any study. Results concerning treatment- or transplantation-related mortality could not be adequately assessed due to substantial differences in definitions between trials and low reporting quality. AUTHORS' CONCLUSIONS We did not consider any study to be sufficiently informative for contemporary treatment decisions concerning the question single versus tandem ASCT in view of inherent biases. In addition, none of the trials integrated the so-called "novel agents" which are now considered standard treatment for MM. To improve the quality of future studies, sample size calculations should consider the potentially steep decrease in compliance with the second ASCT. Reporting of results of treatment- or transplantation-related mortality should clearly specify the type and number of events (the numerator) in a well-defined population (the denominator).
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Taves DR. Rank-Minimization with a two-step analysis should replace randomization in clinical trials. J Clin Epidemiol 2012; 65:3-6. [DOI: 10.1016/j.jclinepi.2011.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 06/10/2011] [Accepted: 06/13/2011] [Indexed: 10/15/2022]
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Lloyd C, Logan S, McHugh C, Humphreys G, Parker S, Beswick D, Beswick M, Rogers M, Thompson-Coon J, Morris C, Wyatt K. Sleep positioning for children with cerebral palsy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cai HW, Xia JL, Gao DH, Cao XM. Implementation and experience of a web-based allocation system with Pocock and Simon's minimization methods. Contemp Clin Trials 2010; 31:510-3. [DOI: 10.1016/j.cct.2010.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 07/22/2010] [Indexed: 11/15/2022]
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18
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Kajimoto K, Miyauchi K, Kasai T, Shimada K, Kojima Y, Shimada A, Niinami H, Amano A, Daida H. Short-term 20-mg atorvastatin therapy reduces key inflammatory factors including c-Jun N-terminal kinase and dendritic cells and matrix metalloproteinase expression in human abdominal aortic aneurysmal wall. Atherosclerosis 2009; 206:505-511. [PMID: 19406402 DOI: 10.1016/j.atherosclerosis.2009.03.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 03/30/2009] [Accepted: 03/30/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) accumulates features of a chronic inflammatory disorder and irreversible destruction of connective tissue. A recent experimental study identified c-Jun N terminal kinase (JNK) as a proximal signaling molecule in the pathogenesis of AAA and vascular dendritic cells as key players in the inflammatory reaction and degradation of the extracellular matrix. Statins can inhibit cell proliferation and vascular inflammation, which might help prevent AAA progression. However, supporting clinical data from human studies are lacking. We hypothesized that atorvastatin might inhibit JNK and dendritic cells, resulting in suppression of inflammatory cells and matrix metalloproteinases (MMPs) in human tissue of AAA. METHODS Patients with AAA were randomized to atorvastatin (20mg/day, n=10) and non-treated (n=10) groups. After treatment for 4 weeks, patients underwent abdominal aorta replacement, tissue specimens were obtained, and tissue composition was assessed using immunohistochemistry with quantitative image analysis. RESULTS Atorvastatin significantly reduced expression of JNK (1.1% vs. 8.1%, P=0.0002) and dendritic cells (3.2 vs. 7.2, P=0.003) compared to controls. T cells (142 vs. 315, P=0.008), macrophages (13 vs. 24, P=0.048) and immunoreactivity to MMP-2 (7.8% vs. 21%, P=0.049) and MMP-9 (13% vs. 24%, P=0.028) were also suppressed in the atorvastatin group. Serum low-density lipoprotein cholesterol level was decreased by 40% in the atorvastatin group. CONCLUSIONS Atorvastatin treatment acutely reduces JNK expression and dendritic cells, resulting in reduced inflammatory cell content and expression of MMPs in the AAA wall.
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Affiliation(s)
- Kan Kajimoto
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
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Bagshaw SM, Bellomo R. The need to reform our assessment of evidence from clinical trials: a commentary. Philos Ethics Humanit Med 2008; 3:23. [PMID: 18826605 PMCID: PMC2569956 DOI: 10.1186/1747-5341-3-23] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 09/30/2008] [Indexed: 05/26/2023] Open
Abstract
The ideology of evidence-based medicine (EBM) has dramatically altered the way we think, conceptualize, philosophize and practice medicine. One of its major pillars is the appraisal and classification of evidence. Although important and beneficial, this process currently lacks detail and is in need of reform. In particular, it largely focuses on three key dimensions (design, [type I] alpha error and beta [type II] error) to grade the quality of evidence and often omits other crucial aspects of evidence such as biological plausibility, reproducibility, generalizability, temporality, consistency and coherence. It also over-values the randomized trial and meta-analytical techniques, discounts the biasing effect of single centre execution and gives insufficient weight to large and detailed observational studies. Unless these aspects are progressively included into systems for grading, evaluating and classifying evidence and duly empirically assessed (according to the EBM paradigm), the EBM process and movement will remain open to criticism of being more evidence-biased than evidence-based."All scientific work is incomplete--whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time". (Sir Bradford Austin Hill 1).
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University School of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia
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Kang M, Ragan BG, Park JH. Issues in outcomes research: an overview of randomization techniques for clinical trials. J Athl Train 2008; 43:215-21. [PMID: 18345348 DOI: 10.4085/1062-6050-43.2.215] [Citation(s) in RCA: 261] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To review and describe randomization techniques used in clinical trials, including simple, block, stratified, and covariate adaptive techniques. BACKGROUND Clinical trials are required to establish treatment efficacy of many athletic training procedures. In the past, we have relied on evidence of questionable scientific merit to aid the determination of treatment choices. Interest in evidence-based practice is growing rapidly within the athletic training profession, placing greater emphasis on the importance of well-conducted clinical trials. One critical component of clinical trials that strengthens results is random assignment of participants to control and treatment groups. Although randomization appears to be a simple concept, issues of balancing sample sizes and controlling the influence of covariates a priori are important. Various techniques have been developed to account for these issues, including block, stratified randomization, and covariate adaptive techniques. ADVANTAGES Athletic training researchers and scholarly clinicians can use the information presented in this article to better conduct and interpret the results of clinical trials. Implementing these techniques will increase the power and validity of findings of athletic medicine clinical trials, which will ultimately improve the quality of care provided.
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Affiliation(s)
- Minsoo Kang
- Middle Tennessee State University, Murfreesboro, TN, USA
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21
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Del Boca FK, Darkes J. Enhancing the validity and utility of randomized clinical trials in addictions treatment research: I. Treatment implementation and research design. Addiction 2007; 102:1047-56. [PMID: 17567393 DOI: 10.1111/j.1360-0443.2007.01862.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE This paper is the first in a series that examines methods for improving the validity and utility of randomized clinical trials (RCTs) in addictions treatment research. The specific foci of this article are treatment implementation and research design. SCOPE We begin by considering the conditions under which the RCT provides an appropriate design choice. Sections that follow discuss methodological issues with respect to RCT structure and collaborative arrangements; treatment specification, delivery and cost; experimental design; and randomization/blinding procedures. We emphasize the importance of advance planning; treatment integrity and discriminability; treatment standardization; staff training and supervision; client compliance; maintenance of between-group equivalence across study conditions; and inclusion of appropriate comparison groups in study designs. CONCLUSIONS Investigators are encouraged to maximize the internal validity of RCTs, but also to consider methods for enhancing external validity. The utility of addictions RCTs for advancing theory and improving clinical practice can be enhanced by investigating underlying mechanisms of action.
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Affiliation(s)
- Frances K Del Boca
- Department of Psychology, University of South Florida, Tampa, FL 33620-8200, USA.
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Jansen YJFM, Bal R, Bruijnzeels M, Foets M, Frenken R, de Bont A. Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice. BMC Health Serv Res 2006; 6:160. [PMID: 17166255 PMCID: PMC1713235 DOI: 10.1186/1472-6963-6-160] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Accepted: 12/13/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this paper is to show how researchers balance between scientific rigour and localisation in conducting pragmatic trial research. Our case is the Quattro Study, a pragmatic trial on the effectiveness of multidisciplinary patient care teams used in primary health care centres in deprived neighbourhoods of two major cities in the Netherlands for intensified secondary prevention of cardiovascular diseases. METHODS For this study an ethnographic design was used. We observed and interviewed the researchers and the practice nurses. All gathered research documents, transcribed observations and interviews were analysed thematically. RESULTS Conducting a pragmatic trial is a continuous balancing act between meeting methodological demands and implementing a complex intervention in routine primary health care. As an effect, the research design had to be adjusted pragmatically several times and the intervention that was meant to be tailor-made became a rather stringent procedure. CONCLUSION A pragmatic trial research is a dynamic process that, in order to be able to assess the validity and reliability of any effects of interventions must also have a continuous process of methodological and practical reflection. Ethnographic analysis, as we show, is therefore of complementary value.
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Affiliation(s)
- Yvonne JFM Jansen
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Roland Bal
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Marc Bruijnzeels
- Stichting Lijn 1 Haaglanden, P.O.Box 138, 2270 ACVoorburg, The Netherlands
| | - Marleen Foets
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Rianne Frenken
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
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Cai H, Xia J, Xu D, Gao D, Yan Y. A generic minimization random allocation and blinding system on web. J Biomed Inform 2006; 39:706-19. [PMID: 16616696 DOI: 10.1016/j.jbi.2006.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 12/22/2005] [Accepted: 02/21/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND Minimization is a dynamic randomization method for clinical trials. Although recommended by many researchers, the utilization of minimization has been seldom reported in randomized trials mainly because of the controversy surrounding the validity of conventional analyses and its complexity in implementation. However, both the statistical and clinical validity of minimization were demonstrated in recent studies. Minimization random allocation system integrated with blinding function that could facilitate the implementation of this method in general clinical trials has not been reported. SYSTEM OVERVIEW: The system is a web-based random allocation system using Pocock and Simon minimization method. It also supports multiple treatment arms within a trial, multiple simultaneous trials, and blinding without further programming. METHODS This system was constructed with generic database schema design method, Pocock and Simon minimization method and blinding method. It was coded with Microsoft Visual Basic and Active Server Pages (ASP) programming languages. And all dataset were managed with a Microsoft SQL Server database. Some critical programming codes were also provided. SIMULATIONS AND RESULTS: Two clinical trials were simulated simultaneously to test the system's applicability. Not only balanced groups but also blinded allocation results were achieved in both trials. DISCUSSIONS AND CONCLUSIONS Practical considerations for minimization method, the benefits, general applicability and drawbacks of the technique implemented in this system are discussed. Promising features of the proposed system are also summarized.
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Affiliation(s)
- Hongwei Cai
- Network Center, Fourth Military Medical University, No. 17 Changle West Road, Xi'an, Shaanxi 710032, China
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MacDermid JC, Solomon P, Law M, Russell D, Stratford P. Defining the effect and mediators of two knowledge translation strategies designed to alter knowledge, intent and clinical utilization of rehabilitation outcome measures: a study protocol [NCT00298727]. Implement Sci 2006; 1:14. [PMID: 16820055 PMCID: PMC1557530 DOI: 10.1186/1748-5908-1-14] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 07/04/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A substantial number of valid outcome measures have been developed to measure health in adult musculoskeletal and childhood disability. Regrettably, national initiatives have merely resulted in changes in attitude, while utilization remains unacceptably low. This study will compare the effectiveness and mediators of two different knowledge transfer (KT) interventions in terms of their impact on changing knowledge and behavior (utilization and clinical reasoning) related to health outcome measures. METHOD/DESIGN Physical and occupational therapists (n = 144) will be recruited in partnership with the national professional associations to evaluate two different KT interventions with the same curriculum: 1) Stakeholder-Hosted Interactive Problem-Based Seminar (SHIPS), and 2) Online Problem-Based course (e-PBL). SHIPS will consist of face-to-face problem-based learning (PBL) for 2 1/2 days with outcome measure developers as facilitators, using six problems generated in consultation with participants. The e-PBL will consist of a 6-week web-based course with six generic problems developed by content experts. SHIPS will be conducted in three urban centers in Canada. Participants will be block-allocated by a minimization procedure to either of the two interventions to minimize any prognostic differences. Trained evaluators at each site will conduct chart audits and chart-stimulated recall. Trained interviewers will conduct semi-structured interviews focused on identifying critical elements in KT and implementing practice changes. Interviews will be transcribed verbatim. Baseline predictors including demographics, knowledge, attitudes/barriers regarding outcome measures, and Readiness to Change will be assessed by self-report. Immediately post-intervention and 6 months later, these will be re-administered. Primary qualitative and quantitative evaluations will be conducted 6-months post-intervention to assess the relative effectiveness of KT interventions and to identify elements that contribute to changing clinical behavior. Chart audits will determine the utilization of outcome measures (counts). Incorporation of outcome measures into clinical reasoning will be assessed using an innovative technique: chart-stimulated recall. DISCUSSION A strategy for optimal transfer of health outcome measures into practice will be developed and shared with multiple disciplines involved in primary and specialty management of musculoskeletal and childhood disability.
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Affiliation(s)
- Joy C MacDermid
- School of Rehabilitation Science, McMaster University, 1400 Main St. West, IAHS-403, Hamilton, Ontario, L8S 1C7, Canada
- Hand and Upper Limb Centre Clinical Research Laboratory, St. Joseph's Health Centre, 268 Grosvenor St., London, Ontario, N6A 3A8, Canada
| | - Patty Solomon
- School of Rehabilitation Science, McMaster University, 1400 Main St. West, IAHS-403, Hamilton, Ontario, L8S 1C7, Canada
| | - Mary Law
- School of Rehabilitation Science, McMaster University, 1400 Main St. West, IAHS-403, Hamilton, Ontario, L8S 1C7, Canada
| | - Dianne Russell
- School of Rehabilitation Science, McMaster University, 1400 Main St. West, IAHS-403, Hamilton, Ontario, L8S 1C7, Canada
| | - Paul Stratford
- School of Rehabilitation Science, McMaster University, 1400 Main St. West, IAHS-403, Hamilton, Ontario, L8S 1C7, Canada
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Glasgow RE, Davidson KW, Dobkin PL, Ockene J, Spring B. Practical behavioral trials to advance evidence-based behavioral medicine. Ann Behav Med 2006; 31:5-13. [PMID: 16472033 DOI: 10.1207/s15324796abm3101_3] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
There is a well-documented gap between research and practice in many areas of behavioral medicine. This gap is due in part to limitations in the capacity of the research database to address questions that are of central concern to clinicians, administrative decision makers, and policymakers. Thus, there has been a call for "practical clinical trials" that compare clinically viable alternative interventions and assess multiple outcomes important for clinical and policy decisions in diverse patient populations and settings. Such trials offer great potential, and they raise interesting challenges regarding optimal research design and source of funding. We discuss issues related to practical clinical trials in behavioral medicine, propose a need for practical behavioral trials (PBTs), and describe design features that will facilitate clinical and policy decision making. This type of PBT can help to close the gap between research and practice and advance the field of evidence-based behavioral medicine. We discuss potential challenges and objections to PBTs and conclude by providing recommendations for the design, conduct, reporting, and review of practical trials.
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Abstract
The term cerebral palsy refers to a range of clinical symptoms, with related service requirements, resulting from lesions or abnormalities in the brain arising early in life. It is not a diagnosis; aetiology and pathology are variable. This article discusses the definition and differential classification of cerebral palsy, describes trends in its frequency over time stratified by associated variables, and briefly reviews the most recent findings concerning its aetiology.
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Affiliation(s)
- Eve Blair
- Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia, P.O. Box 855, West Perth, WA 6872, Australia.
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