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Butler CC. Democratising the design and delivery of large-scale randomised, controlled clinical trials in primary care: A personal view. Eur J Gen Pract 2024; 30:2293702. [PMID: 38180050 PMCID: PMC10773679 DOI: 10.1080/13814788.2023.2293702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Rapid identification of effective treatments for use in the community during a pandemic is vital for the well-being of individuals and the sustainability of healthcare systems and society. Furthermore, identifying treatments that do not work reduces research wastage, spares people unnecessary side effects, rationalises the cost of purchasing and stockpiling medication, and reduces inappropriate medication use. Nevertheless, only a small minority of therapeutic trials for SARS-CoV-2 infections have been in primary care: most opened too late, struggled to recruit, and few produced actionable results. Participation in research is often limited by where one lives or receives health care, and trial participants may not represent those for whom the treatments are intended. INNOVATIVE TRIALS The ALIC4E, PRINCIPLE and the ongoing PANORAMIC trial have randomised over 40,500 people with COVID-19. This personal view describes how these trials have innovated in: trial design (by using novel adaptive platform designs); trial delivery (by complementing traditional site-based recruitment ('the patient comes to the research') with mechanisms to enable sick, infectious people to participate without having to leave home ('taking research to the people'), and by addressing the 'inverse research participation law,' which highlights disproportionate barriers faced by those who have the most to contribute, and benefit from, research, and; in transforming the evidence base by evaluating nine medicines to support guidelines and care decisions world-wide for COVID-19 and contribute to antimicrobial stewardship. CONCLUSION The PRINCIPLE and PANORAMIC trials represent models of innovation and inclusivity, and exemplify the potential of primary care to lead the way in addressing pressing global health challenges.
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Affiliation(s)
- Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, Primary Care Clinical Trials Unit, University of Oxford, Oxford, United Kingdom
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Turner KM, Huntley A, Yardley T, Dawson S, Dawson S. Defining usual care comparators when designing pragmatic trials of complex health interventions: a methodology review. Trials 2024; 25:117. [PMID: 38342896 PMCID: PMC10860249 DOI: 10.1186/s13063-024-07956-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Pragmatic trials evaluating complex health interventions often compare them to usual care. This comparator should resemble care as provided in everyday practice. However, usual care can differ for the same condition, between patients and practitioners, across clinical sites and over time. Heterogeneity within a usual care arm can raise methodological and ethical issues. To address these it may be necessary to standardise what usual care entails, although doing so may compromise a trial's external validity. Currently, there is no guidance detailing how researchers should decide the content of their usual care comparators. We conducted a methodology review to summarise current thinking about what should inform this decision. METHODS MEDLINE, Embase, CINAHL and PsycINFO were searched from inception to January 2022. Articles and book chapters that discussed how to identify or develop usual care comparators were included. Experts in the field were also contacted. Reference lists and forward citation searches of included articles were screened. Data were analysed using a narrative synthesis approach. RESULTS One thousand nine hundred thirty records were identified, 1611 titles and abstracts screened, 112 full texts screened, and 16 articles included in the review. Results indicated that the content of a usual care comparator should be informed by the aims of the trial, existing care practices, clinical guidelines, and characteristics of the target population. Its content should also be driven by the trial's requirements to protect participants, inform practice, and be methodologically robust, efficient, feasible and acceptable to stakeholders. When deciding the content of usual care, researchers will need to gather information about these drivers, balance tensions that might occur when responding to different trial objectives, and decide how usual care will be described and monitored in the trial. DISCUSSION When deciding the content of a usual care arm, researchers need to understand the context in which a trial will be implemented and what the trial needs to achieve to address its aim and remain ethical. This is a complex decision-making process and trade-offs might need to be made. It also requires research and engagement with stakeholders, and therefore time and funding during the trial's design phase. TRIAL REGISTRATION PROSPERO CRD42022307324.
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Affiliation(s)
- Katrina M Turner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Alyson Huntley
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tom Yardley
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shoba Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Parker SM, Aslani P, Harris-Roxas B, Wright MC, Barr M, Doolan-Noble F, Javanparast S, Sharma A, Osborne RH, Cullen J, Harris E, Haigh F, Harris M. Community health navigator-assisted transition of care from hospital to community: protocol for a randomised controlled trial. BMJ Open 2024; 14:e077877. [PMID: 38309760 PMCID: PMC10840031 DOI: 10.1136/bmjopen-2023-077877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/12/2024] [Indexed: 02/05/2024] Open
Abstract
INTRODUCTION The objective of this parallel group, randomised controlled trial is to evaluate a community health navigator (CHN) intervention provided to patients aged over 40 years and living with chronic health conditions to transition from hospital inpatient care to their homes. Unplanned hospital readmissions are costly for the health system and negatively impact patients. METHODS AND ANALYSIS Patients are randomised post hospital discharge to the CHN intervention or usual care. A comparison of outcomes between intervention and control groups will use multivariate regression techniques that adjust for age, sex and any independent variables that are significantly different between the two groups, using multiple imputation for missing values. Time-to-event analysis will examine the relationship between seeing a CHN following discharge from the index hospitalisation and reduced rehospitalisations in the subsequent 60 days and 6 months. Secondary outcomes include medication adherence, health literacy, quality of life, experience of healthcare and health service use (including the cost of care). We will also conduct a qualitative assessment of the implementation of the navigator role from the viewpoint of stakeholders including patients, health professionals and the navigators themselves. ETHICS APPROVAL Ethics approval was obtained from the Research Ethics and Governance Office, Sydney Local Health District, on 21 January 2022 (Protocol no. X21-0438 and 2021/ETH12171). The findings of the trial will be disseminated through peer-reviewed journals and national and international conference presentations. Data will be deposited in an institutional data repository at the end of the trial. This is subject to Ethics Committee approval, and the metadata will be made available on request. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN 12622000659707). ARTICLE SUMMARY The objective of this trial is to evaluate a CHN intervention provided to patients aged over 40 years and living with chronic health conditions to transition from hospital inpatient care to their homes.
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Affiliation(s)
- Sharon M Parker
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Parisa Aslani
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Ben Harris-Roxas
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael C Wright
- Health Economics Research and Evaluation, University of Technology, Sydney, New South Wales, Australia
| | - Margo Barr
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - F Doolan-Noble
- General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Sara Javanparast
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Anurag Sharma
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard H Osborne
- Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - John Cullen
- Aged Health, Rehabilitation and Chronic Care, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Elizabeth Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Fiona Haigh
- Centre for Health Equity Training, Research and Evaluation, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
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Beck AK, Baker AL, Britton B, Lum A, Pohlman S, Forbes E, Moore L, Barnoth D, Perkes SJ, Oldmeadow C, Carter G. Adapted motivational interviewing for brief healthcare consultations: A systematic review and meta-analysis of treatment fidelity in real-world evaluations of behaviour change counselling. Br J Health Psychol 2023; 28:972-999. [PMID: 37144242 PMCID: PMC10947272 DOI: 10.1111/bjhp.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/23/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Behaviour change counselling (BCC) is an adaptation of motivational interviewing (MI) designed to maximize the effectiveness of time-limited health behaviour change consultations. To improve intervention quality and understanding of treatment effects, it is recommended that evaluations of health behaviour change interventions incorporate existing fidelity frameworks (e.g. The National Institutes of Health [NIH] Behaviour Change Consortium) and ensure that treatment fidelity is assessed and reported. PURPOSE This systematic review was designed to examine (a) adherence to NIH fidelity recommendations, (b) provider fidelity to BCC and (c) impact of these variables on the real-world effectiveness of BCC for adult health behaviours and outcomes. METHODS AND RESULTS Searches of 10 electronic databases yielded 110 eligible publications describing 58 unique studies examining BCC delivered within real-world healthcare settings by existing providers. Mean study adherence to NIH fidelity recommendations was 63.31% (Range 26.83%-96.23%). Pooled effect size (Hedges g) for short-term and long-term outcomes was .19 (95% CI [.11, .27]) and .09 (95% CI [.04, .13]), respectively. In separate, random-effects meta-regressions, neither short-term nor long-term effect sizes were significantly modified by adherence to NIH fidelity recommendations. For the subgroup of short-term alcohol studies (n = 10), a significant inverse relationship was detected (Coefficient = -.0114, 95% CI [-.0187, -.0041], p = .0021). Inadequate and inconsistent reporting within the included studies precluded planned meta-regression between provider fidelity and BCC effect size. CONCLUSIONS Further evidence is needed to clarify whether adherence to fidelity recommendations modifies intervention effects. Efforts to promote transparent consideration, evaluation and reporting of fidelity are urgently needed. Research and clinical implications are discussed.
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Affiliation(s)
- Alison K. Beck
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Amanda L. Baker
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Ben Britton
- Hunter New England HealthNew LambtonNew South WalesAustralia
| | - Alistair Lum
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Sonja Pohlman
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Erin Forbes
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Lyndell Moore
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Ditte Barnoth
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Sarah J. Perkes
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Chris Oldmeadow
- Clinical Research Design and Statistical ServiceHunter Medical Research InstituteNew Lambton HeightsNew South WalesAustralia
| | - Gregory Carter
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
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Edwards R, Way S, Hundley VA. Let's talk early labour: The L-TEL randomised controlled trial. Women Birth 2023; 36:552-560. [PMID: 37562988 DOI: 10.1016/j.wombi.2023.07.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/30/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Women without complications have lower obstetric intervention if they remain at home in early labour but many women report dissatisfaction in doing this. Using self-efficacy theory as an underpinning framework, a web-based intervention was co-created with women who had previously used maternity services. The intervention provides early labour advice, alongside the videoed, real experiences of women. METHOD The pragmatic, randomised control trial aimed to evaluate the impact of the web-based intervention on women's self-reported experiences of early labour. Low-risk, nulliparous, pregnant women (140) were randomised. The intervention group (69) received the web-based intervention antenatally to use at their own convenience and the control group (71) received usual care. Data were collected at 7-28 days postnatally using an online version of the Early Labour Experience Questionnaire (ELEQ). The primary outcome was the ELEQ score. Secondary, clinical outcomes such as labour onset, augmentation and mode of birth were collected from the existing hospital system. RESULTS There were no statistically significant differences in the ELEQ scores between trial arms. Women in the intervention group were significantly more likely to progress spontaneously in labour without the need for labour augmentation (39.1 %) compared to the control group (21.1 %) (OR 2.41, CI 95 %; 1.14-5.11). CONCLUSION Although the L-TEL Trial found no statistically significant differences in the primary outcome, the innovative intervention to support women during latent phase labour was positively received by women. Web-based resources are a cost effective, user-friendly and accessible way to provide women with education. A larger trial is needed to detect differences in clinical outcomes.
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Affiliation(s)
- Rebecca Edwards
- Frimley Park Hospital, Portsmouth Road, Surrey GU16 7UJ, UK; Centre for Midwifery & Women's Health, Bournemouth University, Bournemouth Gateway Building, St Paul's Lane, Bournemouth BH8 8GP, UK
| | - Susan Way
- Centre for Midwifery & Women's Health, Bournemouth University, Bournemouth Gateway Building, St Paul's Lane, Bournemouth BH8 8GP, UK
| | - Vanora A Hundley
- Centre for Midwifery & Women's Health, Bournemouth University, Bournemouth Gateway Building, St Paul's Lane, Bournemouth BH8 8GP, UK.
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Harvey LA, Glinsky JV, Chu J, Herbert RD, Liu H, Jan S, Billot L, Scivoletto G, Spooren AI, Seelen HA, Ben M, Tranter K, Chen LW, Rainey D, Rimmer C, Jorgensen V, Di Natal F, Denis S, Gollan EJ, Tamburella F, Agostinello J, van Laake-Geelen CM, Bell C, Lincoln C, Stolwijk JM, van der Lede J, Paddison S, Oostra K, Cameron ID, Weber G, Sherrington C, Nunn AK, Synnott EL, McCaughey E, Kaur J, Shetty S. Early and intensive motor training to enhance neurological recovery in people with spinal cord injury: trial protocol. Spinal Cord 2023; 61:521-527. [PMID: 37414835 PMCID: PMC10495259 DOI: 10.1038/s41393-023-00908-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
STUDY DESIGN Protocol for a multi-centre randomised controlled trial (the SCI-MT trial). OBJECTIVES To determine whether 10 weeks of intensive motor training enhances neurological recovery in people with recent spinal cord injury (SCI). SETTING Fifteen spinal injury units in Australia, Scotland, England, Italy, Netherlands, Norway, and Belgium. METHODS A pragmatic randomised controlled trial will be undertaken. Two hundred and twenty people with recent SCI (onset in the preceding 10 weeks, American Spinal Injuries Association Impairment Scale (AIS) A lesion with motor function more than three levels below the motor level on one or both sides, or an AIS C or D lesion) will be randomised to receive either usual care plus intensive motor training (12 h of motor training per week for 10 weeks) or usual care alone. The primary outcome is neurological recovery at 10 weeks, measured with the Total Motor Score from the International Standards for Neurological Classification of SCI. Secondary outcomes include global measures of motor function, ability to walk, quality of life, participants' perceptions about ability to perform self-selected goals, length of hospital stay and participants' impressions of therapeutic benefit at 10 weeks and 6 months. A cost-effectiveness study and process evaluation will be run alongside the trial. The first participant was randomised in June 2021 and the trial is due for completion in 2025. CONCLUSIONS The findings of the SCI-MT Trial will guide recommendations about the type and dose of inpatient therapy that optimises neurological recovery in people with SCI. TRIAL REGISTRATION ACTRN12621000091808 (1.2.2021).
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Affiliation(s)
- Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia.
| | - Joanne V Glinsky
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Jackie Chu
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | | | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Henk A Seelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Marsha Ben
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Keira Tranter
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Lydia W Chen
- Royal North Shore Hospital, Sydney, NSW, Australia
| | | | | | | | | | - Sophie Denis
- Prince of Wales Hospital, Sydney, NSW, Australia
| | | | | | | | - Charlotte M van Laake-Geelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Chris Bell
- Repatriation General Hospital, Adelaide, SA, Australia
| | - Claire Lincoln
- Queen Elizabeth National Spinal Injures Unit, Glasgow, UK
| | - Janneke M Stolwijk
- Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Jessica van der Lede
- Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Sue Paddison
- London Spinal Cord Injury Centre, Royal National Orthopaedic Hospital Trust, Middlesex, UK
| | | | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | | | - Catherine Sherrington
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Andrew K Nunn
- Victorian Spinal Cord Service, Austin Health, Melbourne, VIC, Australia
| | | | - Euan McCaughey
- Queen Elizabeth National Spinal Injures Unit, Glasgow, UK
| | - Jasbeer Kaur
- Royal North Shore Hospital, Sydney, NSW, Australia
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Bjørkedal STB, Bejerholm U, Hjorthøj C, Møller T, Eplov LF. Meaningful Activities and Recovery (MA&R): a co-led peer occupational therapy intervention for people with psychiatric disabilities. Results from a randomized controlled trial. BMC Psychiatry 2023; 23:406. [PMID: 37280561 DOI: 10.1186/s12888-023-04875-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/16/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Activity and participation are critical to health and wellbeing. Limited evidence exists on how to support people with mental illness in participating in everyday activities. AIM To investigate the effectiveness of Meaningful Activities and Recovery (MA&R), a co-led peer occupational therapy intervention focusing on activity engagement, functioning, quality of life, and personal recovery. METHODS In a statistician blinded, multicenter RCT including 139 participants from seven community and municipal mental health services in Denmark, participants were randomly assigned to 1) MA&R and standard mental health care or 2) standard mental health care. The MA&R intervention lasted 8 months and consisted of 11 group sessions, 11 individual sessions, and support to engage in activities. The primary outcome, activity engagement, was measured using Profile of Occupational Engagement in People with Severe Mental Illness (POES-S). Outcomes were measured at baseline and post-intervention follow-up. RESULTS Meaningful Activities and Recovery was delivered with high fidelity and 83% completed the intervention. It did not demonstrate superiority to standard mental health care, as intention-to treat analysis revealed no significant differences between the groups in activity engagement or any of the secondary outcomes. CONCLUSION We did not find positive effects of MA&R, possibly because of COVID-19 and related restrictions. Fidelity assessments and adherence rates suggest that MA&R is feasible and acceptable. However, future studies should focus on refining the intervention before investigating its effectiveness. TRIAL REGISTRATION The trial was registered 24/05/2019 at ClinicalTrials.gov NCT03963245.
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Affiliation(s)
| | - Ulrika Bejerholm
- Department of Health Sciences, Centre of Evidence-Based Psychosocial Interventions, CEPI, Lund University, Lund, Sweden
- Department of Research, Development and Education, Division of Psychiatry and Habilitation, Region Skåne, Lund, Sweden
| | - Carsten Hjorthøj
- CORE: Copenhagen Research for Mental Health, Gentofte Hospitalsvej 15, 3A, 2900, Hellerup, Denmark
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen K, Denmark
| | - Tom Møller
- University Hospitals Centre for Health Research (UCSF), Department 9701, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen K, Denmark
| | - Lene Falgaard Eplov
- CORE: Copenhagen Research for Mental Health, Gentofte Hospitalsvej 15, 3A, 2900, Hellerup, Denmark
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Al-Najjar N, Bray L, Carter B, Castle AP, Collingwood A, Cook G, Crudgington H, Currier J, Dietz KC, Hardy WAS, Hiscock H, Hughes D, Morris C, Roberts D, Rouncefield-Swales A, Saron H, Spowart C, Stibbs-Eaton L, Tudur Smith C, Watson V, Whittle L, Wiggs L, Wood E, Gringras P, Pal DK. Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E: a protocol for a randomised controlled trial comparing an online behavioural sleep intervention with standard care in children with Rolandic epilepsy. BMJ Open 2023; 13:e065769. [PMID: 36898757 PMCID: PMC10008377 DOI: 10.1136/bmjopen-2022-065769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Sleep and epilepsy have an established bidirectional relationship yet only one randomised controlled clinical trial has assessed the effectiveness of behavioural sleep interventions for children with epilepsy. The intervention was successful, but was delivered via face-to-face educational sessions with parents, which are costly and non-scalable to population level. The Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E trial addresses this problem by comparing clinical and cost-effectiveness in children with Rolandic epilepsy between standard care (SC) and SC augmented with a novel, tailored parent-led CASTLE Online Sleep Intervention (COSI) that incorporates evidence-based behavioural components. METHODS AND ANALYSES CASTLE Sleep-E is a UK-based, multicentre, open-label, active concurrent control, randomised, parallel-group, pragmatic superiority trial. A total of 110 children with Rolandic epilepsy will be recruited in outpatient clinics and allocated 1:1 to SC or SC augmented with COSI (SC+COSI). Primary clinical outcome is parent-reported sleep problem score (Children's Sleep Habits Questionnaire). Primary health economic outcome is the incremental cost-effectiveness ratio (National Health Service and Personal Social Services perspective, Child Health Utility 9D Instrument). Parents and children (≥7 years) can opt into qualitative interviews and activities to share their experiences and perceptions of trial participation and managing sleep with Rolandic epilepsy. ETHICS AND DISSEMINATION The CASTLE Sleep-E protocol was approved by the Health Research Authority East Midlands (HRA)-Nottingham 1 Research Ethics Committee (reference: 21/EM/0205). Trial results will be disseminated to scientific audiences, families, professional groups, managers, commissioners and policymakers. Pseudo-anonymised individual patient data will be made available after dissemination on reasonable request. TRIAL REGISTRATION NUMBER ISRCTN13202325.
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Affiliation(s)
- Nadia Al-Najjar
- Liverpool Clinical Trials Centre, Institute of Population Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Lucy Bray
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Bernie Carter
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Advisory Panel Castle
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Amber Collingwood
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Georgia Cook
- Centre for Psychological Research, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Holly Crudgington
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Janet Currier
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Kristina Charlotte Dietz
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Will A S Hardy
- Centre for Health Economics and Medicines Evaluation, School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Harriet Hiscock
- Centre for Community Child Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Christopher Morris
- University of Exeter Medical School, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Deborah Roberts
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Alison Rouncefield-Swales
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Holly Saron
- Department of Nursing & Midwifery, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Catherine Spowart
- Liverpool Clinical Trials Centre, Institute of Population Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Lucy Stibbs-Eaton
- Liverpool Clinical Trials Centre, Institute of Population Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, Institute of Population Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Victoria Watson
- Department of Health Data Science, Institute of Population Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Liam Whittle
- Department of Health Data Science, Institute of Population Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Luci Wiggs
- Centre for Psychological Research, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Eifiona Wood
- Centre for Health Economics and Medicines Evaluation, School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Paul Gringras
- Department of Sleep Medicine, Evelina London Children's Hospital, London, UK
| | - Deb K Pal
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Boateng D, Kumke T, Vernooij R, Goetz I, Meinecke AK, Steenhuis C, Grobbee D, Zuidgeest MGP. Validation of the GetReal Trial Tool - Facilitating discussion and understanding more pragmatic design choices and their implications. Contemp Clin Trials 2023; 125:107054. [PMID: 36529438 DOI: 10.1016/j.cct.2022.107054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The GetReal Trial Tool is a decision support tool to assess the impact of design choices on generalizability of clinical trials to routine clinical practice, while taking into account the risk of bias, precision, acceptability and operational feasibility. This study describes the validation of the GetReal Trial Tool. METHODS Twelve experts took part in the GetReal Trial tool validation using the protocols of 6 trials conducted with pragmatic elements. The tool entails 7 domains with a total of 43 questions. A pooled Kappa statistic (95% CI) using random effects model was estimated using Open Meta (analyst) software. The possible operational challenges were collated and discussed with the trialists that conducted the trials. RESULTS Agreement in the design choices made for the trial protocols was >50% for all the trials and all teams reached consensus during discussion. The pooled Kappa statistic (95% CI) was 0.236 (0.154-0.318). The GetReal Trial tool highlighted several operational challenges, of which almost half had been experienced previously by the trialists. Out of 25 additional operational challenges mentioned by the trialists, 76% were already highlighted by the tool. The tool was considered helpful to optimize trials right from the design stage. CONCLUSION The GetReal Trial Tool helps to scrutinize the choice of study design in the light of Real World Evidence generation. The tool identifies most of the operational challenges experienced by trialists to date. The tool serves the intended purpose of facilitating discussion and understanding more pragmatic design choices and their implications.
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Affiliation(s)
- Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Robin Vernooij
- Division Internal Medicine and Dermatology, Nephrology & Hypertension, University Medical Center Utrecht, the Netherlands
| | - Iris Goetz
- Department of Value, Evidence and Outcomes (VEO), Eli Lilly & Co. Ltd, Bracknell, UK
| | - Anna-Katharina Meinecke
- Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG
| | | | - Diederick Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mira G P Zuidgeest
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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10
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Darsaut TE, Chagnon M, Raymond J. Reply. AJNR Am J Neuroradiol 2023; 44:E9-E10. [PMID: 36574315 PMCID: PMC9835901 DOI: 10.3174/ajnr.a7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- T E Darsaut
- Department of Surgery, Division of NeurosurgeryMackenzie Health Sciences CentreUniversity of Alberta HospitalEdmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and StatisticsUniversité de MontréalMontreal, Quebec, Canada
| | - J Raymond
- Department of Radiology, Service of Interventional NeuroradiologyCentre Hospitalier de l'Université de MontréalMontreal, Quebec, Canada
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11
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Proposing six criteria to improve reproducibility of “usual care” interventions in back pain trials: a systematic review. J Clin Epidemiol 2022; 149:227-235. [DOI: 10.1016/j.jclinepi.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/25/2022] [Accepted: 05/07/2022] [Indexed: 11/22/2022]
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12
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Zuidgeest MGP, Goetz I, Meinecke AK, Boateng D, Irving EA, van Thiel GJM, Welsing PMJ, Oude-Rengerink K, Grobbee DE, Initiative G. The GetReal Trial Tool: Design, Assess and Discuss Clinical Drug Trials in Light of RWE Generation. J Clin Epidemiol 2021; 149:244-253. [PMID: 34929319 DOI: 10.1016/j.jclinepi.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/25/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
Methodologies incorporating Real World Elements into clinical trial design (also called pragmatic trials) offer an attractive opportunity to assess the effect of a treatment strategy in routine care and as such guide decision making in practice. Uptake of these methods is slow for several reasons, including uncertainty about acceptability of trial results, lack of experience with the methodology and operational challenges. We developed the 'Get Real Trial Tool', an easy-to-use interface, which allows users to assess the impact of design choices on generalisability to routine clinical practice, while taking into account risk of bias, precision, acceptability and operational feasibility. The tool is grounded in the scientific literature on pragmatic trials combined with knowledge of experts from academia, pharmaceutical companies, HTA bodies, patient organisations, and regulators. The aim is to help researchers optimise trial design and facilitate translation of evidence from pragmatic trials to clinical practice. In this paper we describe the development, structure and application of the GetReal Trial Tool.
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Affiliation(s)
- Mira G P Zuidgeest
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Anna-Katharina Meinecke
- Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG
| | - Daniel Boateng
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Elaine A Irving
- Clinical Development, GSK Research & Development Ltd., Stevenage, Hertfordshire, SG1 2NY, UK
| | - Ghislaine J M van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paco M J Welsing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Rheumatology & Clinical immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Katrien Oude-Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Clinical, Zeist, the Netherlands
| | - GetReal Initiative
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Eli Lilly & Co Ltd, Bracknell, UK; Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG; Clinical Development, GSK Research & Development Ltd., Stevenage, Hertfordshire, SG1 2NY, UK; Department of Rheumatology & Clinical immunology, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Clinical, Zeist, the Netherlands
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13
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Boere TM, van Buul LW, Hopstaken RM, van Tulder MW, Twisk JWMR, Verheij TJM, Hertogh CMPM. Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: cluster randomised controlled trial. BMJ 2021; 374:n2198. [PMID: 34548288 PMCID: PMC8453309 DOI: 10.1136/bmj.n2198] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents. DESIGN Pragmatic, cluster randomised controlled trial. SETTING The UPCARE study included 11 nursing home organisations in the Netherlands. PARTICIPANTS 84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020. INTERVENTIONS Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections. MAIN OUTCOME MEASURES The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks). RESULTS Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups. CONCLUSIONS CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance. TRIAL REGISTRATION Netherlands Trial Register NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Rogier M Hopstaken
- Primary Health Care Center, Hapert en Hoogeloon, Hapert, Netherlands
- Star-shl Diagnostic Centers, Etten-Leur, Netherlands
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jos W M R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Theo J M Verheij
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
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Hayward G, Butler CC, Yu LM, Saville BR, Berry N, Dorward J, Gbinigie O, van Hecke O, Ogburn E, Swayze H, Bongard E, Allen J, Tonner S, Rutter H, Tonkin-Crine S, Borek A, Judge D, Grabey J, de Lusignan S, Thomas NPB, Evans PH, Andersson MI, Llewelyn M, Patel M, Hopkins S, Hobbs FDR. Platform Randomised trial of INterventions against COVID-19 In older peoPLE (PRINCIPLE): protocol for a randomised, controlled, open-label, adaptive platform, trial of community treatment of COVID-19 syndromic illness in people at higher risk. BMJ Open 2021; 11:e046799. [PMID: 34145016 PMCID: PMC8214989 DOI: 10.1136/bmjopen-2020-046799] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/14/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION There is an urgent need to idenfy treatments for COVID-19 that reduce illness duration and hospital admission in those at higher risk of a longer illness course and complications. METHODS AND ANALYSIS The Platform Randomised trial of INterventions against COVID-19 In older peoPLE trial is an open-label, multiarm, prospective, adaptive platform, randomised clinical trial to evaluate potential treatments for COVID-19 in the community. A master protocol governs the addition of new interventions as they become available, as well as the inclusion and cessation of existing intervention arms via frequent interim analyses. The first three interventions are hydroxychloroquine, azithromycin and doxycycline. Eligible participants must be symptomatic in the community with possible or confirmed COVID-19 that started in the preceding 14 days and either (1) aged 65 years and over or (2) aged 50-64 years with comorbidities. Recruitment is through general practice, health service helplines, COVID-19 'hot hubs' and directly through the trial website. Participants are randomised to receive either usual care or a study drug plus usual care, and outcomes are collected via daily online symptom diary for 28 days from randomisation. The research team contacts participants and/or their study partner following days 7, 14 and 28 if the online diary is not completed. The trial has two coprimary endpoints: time to first self-report of feeling recovered from possible COVID-19 and hospital admission or death from possible COVID-19 infection, both within 28 days from randomisation. Prespecified interim analyses assess efficacy or futility of interventions and to modify randomisation probabilities that allocate more participants to interventions with better outcomes. ETHICS AND DISSEMINATION Ethical approval Ref: 20/SC/0158 South Central - Berkshire Research Ethics Committee; IRAS Project ID: 281958; EudraCT Number: 2020-001209-22. Results will be presented to policymakers and at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN86534580.
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Affiliation(s)
- Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the Aids Programme of Research in South Africa, Durban, South Africa
| | - Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah Swayze
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sharon Tonner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Judge
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Nicholas P B Thomas
- Windrush Medical Practice, Witney, UK
- Royal College of General Practitioners, London, UK
| | - Philip H Evans
- St Leonard's Research Practice, Exeter, UK
- University of Exeter Medical School, Exeter, UK
| | | | - Martin Llewelyn
- Department of Microbiology and Infection, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Mahendra Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Investigation of Newly Diagnosed Drug-Naive Patients with Systemic Autoimmune Diseases Revealed the Cleaved Peptide Tyrosine Tyrosine (PYY 3-36) as a Specific Plasma Biomarker of Rheumatoid Arthritis. Mediators Inflamm 2021; 2021:5523582. [PMID: 34239365 PMCID: PMC8240466 DOI: 10.1155/2021/5523582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/24/2021] [Accepted: 05/11/2021] [Indexed: 01/27/2023] Open
Abstract
There is a current imperative to reveal more precisely the molecular pathways of early onset of systemic autoimmune diseases (SADs). The investigation of newly diagnosed drug-naive SAD patients might contribute to identify novel disease-specific and prognostic markers. The multiplex analysis of 30 plasma proteins in 60 newly diagnosed drug-naive SADs, such as RA (rheumatoid arthritis, n = 31), SLE (systemic lupus erythematosus, n = 19), and SSc (systemic scleroderma, n = 10) patients, versus healthy controls (HCs, n = 40) was addressed. Thirty plasma cytokines were quantified using the Procarta Plex™ panel. The higher expression of IL-12p40, IL-10, IL-13, IFN-γ, M-CSF, IL-4, NTproBNP, IL-17A, BMP-9, PYY (3-36), GITRL, MMP-12, and TNFRSF6 was associated with RA; IL-12p40, M-CSF, IL-4, GITRL, and NTproBNP were higher in SLE; or NTproBNP, PYY (3-36), and MMP-12 were increased in SSc over HCs, respectively. The cleaved peptide tyrosine tyrosine (PYY 3-36) was elevated in RA (361.6 ± 47.7 pg/ml) vs. HCs (163.96 ± 14.5 pg/ml, mean ± SEM, ∗∗∗p = 4 × 10−5). The CI (95%) was 268.05-455.16 pg/ml for RA vs. 135.55-192.37 pg/ml for HCs. The elevated PYY (3-36) level correlated significantly with the increased IL-4 or GITRL concentration but not with the clinical scores (DAS28, CRP, ESR, RF, aMCV). We are the first to report cleaved PYY (3-36) as a specific plasma marker of therapy-naive RA. Additionally, the multiplex plasma protein analysis supported a disease-specific cytokine pattern in RA, SLE, and SSc, respectively.
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Mooney SS, Grover SR. The persistent pelvic pain study: Factors that influence outcomes in women referred to a public hospital with chronic pelvic pain - A study protocol. Aust N Z J Obstet Gynaecol 2021; 61:E6-E11. [PMID: 33386748 DOI: 10.1111/ajo.13289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Persistent pelvic pain affects between 10-20% of women with a significant impact on their physical and mental health, sexual relationships, families and society. Estimates of the cost to women and the community is over $9 billion/annum. Although endometriosis is considered a leading cause of pelvic pain, no symptoms reliably allow the identification of those with and without endometriosis. Furthermore, the significance of mild endometriosis is now debated. The optimal clinical approach for pelvic pain and endometriosis remains unclear, with increasing evidence of other contributing factors such as central sensitisation. Studies to date have significant limitations due to their sample size, relatively short follow-up, and inclusion of only women with laparoscopically identified endometriosis. AIMS To undertake a real-world study of women referred with pain to gynaecology outpatients of a women's hospital and explore factors influencing three-year outcomes. MATERIALS AND METHODS Five hundred women will be randomised to one of two gynaecology units. The units will provide routine clinical care but their approaches to management of women with pelvic pain and endometriosis differ: one with skilled endoscopic gynaecologists has greater emphasis on surgery, the other, gynaecologists have more medical expertise in managing pain and menstrual problems. Participants will complete six-monthly questionnaires regarding pain and quality of life for three years. This information will not be available to clinicians. Their medical care will be followed from their medical records. The cost of outpatient care and admissions will be calculated. Data will be analysed using STATA software with appropriate post hoc tests. Australian and New Zealand Clinical Trials Registry (ANZCTR:ACTRN12616000150448).
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Affiliation(s)
- Samantha S Mooney
- Endosurgery Department, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Sonia R Grover
- Plenty Gynaecology Unit, Mercy Hospital for Women, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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17
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Byhoff E, Kangovi S, Berkowitz SA, DeCamp M, Dzeng E, Earnest M, Gonzalez CM, Hartigan S, Karani R, Memari M, Roy B, Schwartz MD, Volerman A, DeSalvo K. A Society of General Internal Medicine Position Statement on the Internists' Role in Social Determinants of Health. J Gen Intern Med 2020; 35:2721-2727. [PMID: 32519320 PMCID: PMC7459005 DOI: 10.1007/s11606-020-05934-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Elena Byhoff
- Department of Medicine, Institute for Clinical Research and Health Policy Studies Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Shreya Kangovi
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Seth A Berkowitz
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew DeCamp
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Mark Earnest
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sarah Hartigan
- Department of Medicine, Virginia Commonwealth University, Midlothian, VA, USA
| | - Reena Karani
- Department of Medicine, Medicine and Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milad Memari
- Departments of Medical Education, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brita Roy
- Department of Medicine, Yale Medicine, New Haven, CT, USA
| | - Mark D Schwartz
- Departments of Population Health and of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Anna Volerman
- Department of Medicine, University of Chicago, Chicago, IL, USA
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18
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Al-Shammari MA, Yasir A, Aldoori N, Mohammad H. Using Normalization Process Theory to Evaluate Providing Pediatric Palliative Care at End-of-Life as Web-Based Training Intervention for Nurses: Study Protocol for a Randomized Controlled Trial (Preprint). JMIR Res Protoc 2020; 11:e23783. [DOI: 10.2196/23783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 04/24/2021] [Accepted: 07/05/2021] [Indexed: 11/13/2022] Open
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Rennick-Egglestone S, Elliott R, Smuk M, Robinson C, Bailey S, Smith R, Keppens J, Hussain H, Pollock K, Cuijpers P, Llewellyn-Beardsley J, Ng F, Yeo C, Roe J, Hui A, van der Krieke L, Walcott R, Slade M. Impact of receiving recorded mental health recovery narratives on quality of life in people experiencing psychosis, people experiencing other mental health problems and for informal carers: Narrative Experiences Online (NEON) study protocol for three randomised controlled trials. Trials 2020; 21:661. [PMID: 32690105 PMCID: PMC7370499 DOI: 10.1186/s13063-020-04428-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/17/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mental health recovery narratives have been defined as first-person lived experience accounts of recovery from mental health problems which refer to events or actions over a period of time and which include elements of adversity or struggle, and also self-defined strengths, successes or survival. They are readily available in invariant recorded form, including text, audio or video. Previous studies have provided evidence that receiving recorded recovery narratives can provide benefits to recipients. This protocol describes three pragmatic trials that will be conducted by the Narrative Experiences Online (NEON) study using the NEON Intervention, a web application that delivers recorded recovery narratives to its users. The aim of the NEON Trial is to understand whether receiving online recorded recovery narratives through the NEON Intervention benefits people with experience of psychosis. The aim of the NEON-O and NEON-C trials is to evaluate the feasibility of conducting a definitive trial on the use of the NEON Intervention with people experiencing non-psychosis mental health problems and those who care for others experiencing mental health problems respectively. METHODS The NEON Trial will recruit 683 participants with experience of psychosis. The NEON-O Trial will recruit at least 100 participants with experience of non-psychosis mental health problems. The NEON-C Trial will recruit at least 100 participants with experience of caring for others who have experienced mental health problems. In all three trials, participants will be randomly allocated into one of two arms. Intervention arm participants will receive treatment as usual plus immediate access to the NEON Intervention for 1 year. Control arm participants will receive treatment as usual plus access to the NEON Intervention after 1 year. All participants will complete demographics and outcome measures at baseline, 1 week, 12 weeks and 52 weeks. For the NEON Trial, the primary outcome measure is the Manchester Short Assessment of Quality of Life at 52 weeks, and secondary outcome measures are the CORE-10, Herth Hope Index, Mental Health Confidence Scale and Meaning in Life Questionnaire. A cost-effectiveness analysis will be conducted using data collected through the EQ-5D-5 L and the Client Service Receipt Inventory. DISCUSSION NEON Trial analyses will establish both effectiveness and cost-effectiveness of the NEON Intervention for people with experience of psychosis, and hence inform future clinical recommendations for this population. TRIAL REGISTRATION All trials were prospectively registered with ISRCTN. NEON Trial: ISRCTN11152837 . Registered on 13 August 2018. NEON-C Trial: ISRCTN76355273 . Registered on 9 January 2020. NEON-O Trial: ISRCTN63197153 . Registered on 9 January 2020.
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Affiliation(s)
- Stefan Rennick-Egglestone
- School of Health Sciences, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK.
| | - Rachel Elliott
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Melanie Smuk
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Clare Robinson
- Centre for Primary Care & Public Health, Pragmatic Clinical Trials Unit, Queen Mary University of London, 58 Turner St, London, E1 2AB, UK
| | - Sylvia Bailey
- NEON Lived Experience Advisory Panel, Nottingham, UK
| | - Roger Smith
- NEON Lived Experience Advisory Panel, Nottingham, UK
| | - Jeroen Keppens
- Department of Informatics, King's College London, Bush House, 30 Aldwych, London, WC2B 4BG, UK
| | - Hannah Hussain
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Kristian Pollock
- School of Health Sciences, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joy Llewellyn-Beardsley
- School of Health Sciences, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
| | - Fiona Ng
- School of Health Sciences, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
| | - Caroline Yeo
- School of Health Sciences, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
| | - James Roe
- National Institute for Health Research, ARC East Midlands, University of Nottingham, Triumph Road, Nottingham, NG7 2TU, UK
| | - Ada Hui
- School of Health Sciences, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
| | - Lian van der Krieke
- University Medical Center Groningen, University Center of Psychiatry, University of Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Rianna Walcott
- Department of Digital Humanities, King's College London, Strand, London, WC2R 2LS, UK
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
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20
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Cheung WKW, Wu IXY, Sit RWS, Ho RST, Wong CHL, Wong SYS, Chung VCH. Low-level laser therapy for carpal tunnel syndrome: systematic review and network meta-analysis. Physiotherapy 2020; 106:24-35. [PMID: 32026843 DOI: 10.1016/j.physio.2019.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Splinting is recommended by various organisations as a non-surgical first-line treatment for carpal tunnel syndrome (CTS), despite the limited evidence supporting its effectiveness. Previous studies on the effectiveness of low-level laser therapy (LLLT) have reported mixed results, and this systematic review aimed to resolve this controversy. OBJECTIVE To perform a network meta-analysis (NMA) for evaluating the effectiveness of LLLT compared with other conservative treatments for CTS. METHODS Eighteen electronic databases were searched for potential randomised controlled trials (RCTs). RCTs evaluating LLLT or other non-surgical treatments as an add-on to splinting were included. Included RCTs measured at least one of the following three outcomes with validated instruments: pain, symptom severity and functional status. RESULTS Six RCTs (418 patients) were included. NMA suggested that LLLT plus splinting has the highest probability (75%) of pain reduction, compared with sham laser plus splinting (61%), ultrasound plus splinting (57%) and splinting alone (8%). However, while LLLT plus splinting is significantly more effective than sham laser plus splinting for pain reduction, the magnitude is not clinically significant (Visual Analogue Scale mean difference -0.53cm, 95% confidence interval -1.01 to -0.05cm; P=0.03, I2=25%). The effect of LLLT plus splinting on symptom severity and functional status was not superior to splinting alone. CONCLUSION The use of LLLT in addition to splinting for the management of CTS is not recommended, as LLLT offers limited additional benefits over splining alone in terms of pain reduction, reduction of symptom severity or improved functional status. PROSPERO for systematic reviews and meta-analyses registration number CRD42017082650.
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Affiliation(s)
- W K W Cheung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - I X Y Wu
- Xiang-Ya School of Public Health, Central South University, Changsha, China
| | - R W S Sit
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - R S T Ho
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - C H L Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - S Y S Wong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - V C H Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong; School of Chinese Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
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21
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Butler CC, van der Velden AW, Bongard E, Saville BR, Holmes J, Coenen S, Cook J, Francis NA, Lewis RJ, Godycki-Cwirko M, Llor C, Chlabicz S, Lionis C, Seifert B, Sundvall PD, Colliers A, Aabenhus R, Bjerrum L, Jonassen Harbin N, Lindbæk M, Glinz D, Bucher HC, Kovács B, Radzeviciene Jurgute R, Touboul Lundgren P, Little P, Murphy AW, De Sutter A, Openshaw P, de Jong MD, Connor JT, Matheeussen V, Ieven M, Goossens H, Verheij TJ. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. Lancet 2020; 395:42-52. [PMID: 31839279 DOI: 10.1016/s0140-6736(19)32982-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Antivirals are infrequently prescribed in European primary care for influenza-like illness, mostly because of perceived ineffectiveness in real world primary care and because individuals who will especially benefit have not been identified in independent trials. We aimed to determine whether adding antiviral treatment to usual primary care for patients with influenza-like illness reduces time to recovery overall and in key subgroups. METHODS We did an open-label, pragmatic, adaptive, randomised controlled trial of adding oseltamivir to usual care in patients aged 1 year and older presenting with influenza-like illness in primary care. The primary endpoint was time to recovery, defined as return to usual activities, with fever, headache, and muscle ache minor or absent. The trial was designed and powered to assess oseltamivir benefit overall and in 36 prespecified subgroups defined by age, comorbidity, previous symptom duration, and symptom severity, using a Bayesian piece-wise exponential primary analysis model. The trial is registered with the ISRCTN Registry, number ISRCTN 27908921. FINDINGS Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20-1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74-1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30-1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00-5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group. INTERPRETATION Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2-3 days sooner. FUNDING European Commission's Seventh Framework Programme.
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Affiliation(s)
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emily Bongard
- Department of Primary Care Health Services, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Samuel Coenen
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Department of Primary Care Health Services, University of Oxford, Oxford, UK
| | - Nick A Francis
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Roger J Lewis
- Harbor-UCLA Medical Center, Torrance, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Berry Consultants, Austin, TX, USA
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pär-Daniel Sundvall
- Research and Development Primary Health Care-Region Västra Götaland, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Annelies Colliers
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Andrew W Murphy
- Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - An De Sutter
- Center for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Peter Openshaw
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Menno D de Jong
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Jason T Connor
- ConfluenceStat, Orlando, FL, USA; College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Veerle Matheeussen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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22
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Abstract
Real-world evidence (RWE) is the clinical evidence about benefits or risks of medical products derived from analyzing real world data (RWD), which are data collected through routine clinical practice. This article discusses the advantages and disadvantages of RWE studies, how these studies differ from randomized controlled trials (RCTs), how to overcome barriers to current skepticism about RWE, how FDA is using RWE, how to improve the quality of RWE, and finally the future of RWE trials.
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Affiliation(s)
- David C. Klonoff
- Diabetes Research Institute;
Mills-Peninsula Health Services, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin),
Fellow AIMBE, Diabetes Research Institute, Mills-Peninsula Health Services, 100
S San Mateo Dr, Rm 5147, San Mateo, CA 94401, USA.
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23
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Pawson R. The "pragmatic trial": An essentially contested concept? J Eval Clin Pract 2019; 25:943-954. [PMID: 31313412 DOI: 10.1111/jep.13216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/02/2019] [Accepted: 05/30/2019] [Indexed: 12/13/2022]
Abstract
For over 50 years, clinical research methodology has wrestled with the problem of the lack of correspondence between tests of treatments and applications of treatments. The former comprise of trials featuring scrupulous control of patient eligibility, treatment compliance, clinician expertise, follow-up intensity, and so on. In applying a validated treatment, the practitioner has to confront considerable real-world variation in potential patients and in implementation regimes. The remedy, going by the name of "pragmatic trials," is to conduct clinical trials in conditions corresponding more closely to everyday practice. This solution has proved easier to utter than to execute, and the paper reviews the extensive literature on pragmatic trials, seeking to assess whether it has terminated in clarity or contestation.
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Affiliation(s)
- Ray Pawson
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
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24
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Chung VC, Wong CH, Wu IX, Ching JY, Cheung WK, Yip BH, Chan KL, Cheong PK, Wu JC. Electroacupuncture plus on-demand gastrocaine for refractory functional dyspepsia: Pragmatic randomized trial. J Gastroenterol Hepatol 2019; 34:2077-2085. [PMID: 31117149 DOI: 10.1111/jgh.14737] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/14/2019] [Accepted: 05/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Treatment options for functional dyspepsia (FD) refractory to pharmacological treatments are limited but the effectiveness of electroacupuncture (EA) is uncertain. We assessed the effectiveness of EA combined with on-demand gastrocaine. METHODS We conducted a single-center, assessor-blind, randomized parallel-group 2-arm trial on Helicobacter pylori negative FD patients of the postprandial distress syndrome subtype refractory to proton pump inhibitor, prokinetics, or H2 antagonists. Enrolled participants were block randomized in a 1:1 ratio, with concealed random sequence. The treatment and control groups both received on-demand gastrocaine for 12 weeks, but only those in treatment group were offered 20 sessions of EA over 10 weeks. The primary endpoint was the between-group difference in proportion of patients achieving adequate relief of symptoms at week 12. RESULTS Of 132 participants randomly assigned to EA plus on-demand gastrocaine (n = 66) or on-demand gastrocaine alone (n = 66), 125 (94.7%) completed all follow-up at 12 weeks. The EA group had a compliance rate 97.7%. They had a significantly higher likelihood in achieving adequate symptom relief at 12 weeks, with a clinically relevant number needed to treat (NNT) value of 2.36 (95% CI: 1.74, 3.64). Among secondary outcomes, statistically and clinically significant improvements were observed among global symptom (NNT = 3.85 [95% CI: 2.63, 7.69]); postprandial fullness and early satiation (NNT = 5.00 [95% CI: 2.86, 25.00]); as well as epigastric pain, epigastric burning, and postprandial nausea (NNT = 4.17 [95% CI: 2.56, 11.11]). Adverse events were minimal and nonsignificant. CONCLUSION For refractory FD, EA provides significant, clinically relevant symptom relief when added to on-demand gastrocaine (ChiCTR-IPC-15007109).
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Affiliation(s)
- Vincent Ch Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,School of Chinese Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charlene Hl Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Irene Xy Wu
- Xiang-Ya School of Public Health, Central South University, Chang-Sha, Hu-Nan, China
| | - Jessica Yl Ching
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - William Kw Cheung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Benjamin Hk Yip
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kam Leung Chan
- School of Chinese Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Pui Kuan Cheong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Justin Cy Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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25
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Craig SL, McInroy LB, Eaton AD, Iacono G, Leung VW, Austin A, Dobinson C. An Affirmative Coping Skills Intervention to Improve the Mental and Sexual Health of Sexual and Gender Minority Youth (Project Youth AFFIRM): Protocol for an Implementation Study. JMIR Res Protoc 2019; 8:e13462. [PMID: 31172957 PMCID: PMC6592518 DOI: 10.2196/13462] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/18/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sexual and gender minority youth (SGMY, aged 14-29 years) face increased risks to their well-being, including rejection by family, exclusion from society, depression, substance use, elevated suicidality, and harassment, when compared with their cisgender, heterosexual peers. These perils and a lack of targeted programs for SGMY exacerbate their risk for HIV and other sexually transmitted infections. Cognitive behavioral therapy (CBT) interventions support clients by generating alternative ways of interpreting their problems and beliefs about themselves. CBT, tailored to the experiences of SGMY, may help SGMY improve their mood and coping skills by teaching them how to identify, challenge, and change maladaptive thoughts, beliefs, and behaviors. Based on the promising results of a pilot study, a CBT-informed group intervention, AFFIRM, is being tested in a pragmatic trial to assess its implementation potential. OBJECTIVE The aim of this study is to scale-up implementation and delivery of AFFIRM, an 8-session manualized group coping skills intervention focused on reducing sexual risk behaviors and psychosocial distress among SGMY. Our secondary aim is to decrease sexual risk taking, poor mental health, and internalized homophobia and to increase levels of sexual self-efficacy and proactive coping among SGMY. METHODS SGMY are recruited via flyers at community agencies and organizations, as well as through Web-based advertising. Potential participants are assessed for suitability for the group intervention via Web-based screening and are allocated in a 2:1 fashion to the AFFIRM intervention or a wait-listed control in a stepped wedge wait-list crossover design. The intervention groups are hosted by collaborating community agency sites (CCASs; eg, community health centers and family health teams) across Ontario, Canada. Participants are assessed at prewait (if applicable), preintervention, postintervention, 6-month follow-up, and 12-month follow-up for sexual health self-efficacy and capacity, mental health indicators, internalized homophobia, stress appraisal, proactive and active coping, and hope. Web-based data collection occurs either independently or at CCASs using tablets. Participants in crisis are assessed using an established distress protocol. RESULTS Data collection is ongoing; the target sample is 300 participants. It is anticipated that data analyses will use effect size estimates, paired sample t tests, and repeated measures linear mixed modeling in SPSS to test for differences pre- and postintervention. Descriptive analyses will summarize data and profile all variables, including internal consistency estimates. Distributional assumptions and univariate and multivariate normality of variables will be assessed. CONCLUSIONS AFFIRM is a potentially scalable intervention. Many existing community programs provide safe spaces for SGMY but do not provide skills-based training to deal with the increasingly complex lives of youth. This pragmatic trial could make a significant contribution to the field of intervention research by simultaneously moving AFFIRM into practice and evaluating its impact. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/13462.
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Affiliation(s)
- Shelley L Craig
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Lauren B McInroy
- College of Social Work, The Ohio State University, Columbus, OH, United States
| | - Andrew David Eaton
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Gio Iacono
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Vivian Wy Leung
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Ashley Austin
- Ellen Whiteside McDonnell School of Social Work, Barry University, Miami Shores, FL, United States
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26
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Melnick ER, Jeffery MM, Dziura JD, Mao JA, Hess EP, Platts-Mills TF, Solad Y, Paek H, Martel S, Patel MD, Bankowski L, Lu C, Brandt C, D’Onofrio G. User-centred clinical decision support to implement emergency department-initiated buprenorphine for opioid use disorder: protocol for the pragmatic group randomised EMBED trial. BMJ Open 2019; 9:e028488. [PMID: 31152039 PMCID: PMC6550013 DOI: 10.1136/bmjopen-2018-028488] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The goal of this trial is to determine whether implementation of a user-centred clinical decision support (CDS) system can increase adoption of initiation of buprenorphine (BUP) into the routine emergency care of individuals with opioid use disorder (OUD). METHODS A pragmatic cluster randomised trial is planned to be carried out in 20 emergency departments (EDs) across five healthcare systems over 18 months. The intervention consists of a user-centred CDS integrated into ED clinician electronic workflow and available for guidance to: (1) determine whether patients presenting to the ED meet criteria for OUD, (2) assess withdrawal symptoms and (3) ascertain and motivate patient willingness to initiate treatment. The CDS guides the ED clinician to initiate BUP and facilitate follow-up. The primary outcome is the rate of BUP initiated in the ED. Secondary outcomes are: (1) rates of receiving a referral, (2) fidelity with the CDS and (3) rates of clinicians providing any ED-initiated BUP, referral for ongoing treatment and receiving Drug Addiction Act of 2000 training. Primary and secondary outcomes will be analysed using generalised linear mixed models, with fixed effects for intervention status (CDS vs usual care), prespecified site and patient characteristics, and random effects for study site. ETHICS AND DISSEMINATION The protocol has been approved by the Western Institutional Review Board. No identifiable private information will be collected from patients. A waiver of informed consent was obtained for the collection of data for clinician prescribing and other activities. As a minimal risk implementation study of established best practices, an Independent Study Monitor will be utilised in place of a Data Safety Monitoring Board. Results will be reported in ClinicalTrials.gov and published in open-access, peer-reviewed journals, presented at national meetings and shared with the clinicians at participating sites via a broadcast email notification of publications. TRIAL REGISTRATION NUMBER NCT03658642; Pre-results.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jodi A Mao
- Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yauheni Solad
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Hyung Paek
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Shara Martel
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Laura Bankowski
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Lu
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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27
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Christian JB, Brouwer ES, Girman CJ, Bennett D, Davis KJ, Dreyer NA. Masking in Pragmatic Trials: Who, What, and When to Blind. Ther Innov Regul Sci 2019. [DOI: 10.1177/2168479019843129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Emily S. Brouwer
- Takeda Pharmaceuticals International Co, Global Outcomes Research and Epidemiology, Cambridge, MA, USA
| | | | - Dimitri Bennett
- Takeda Pharmaceuticals, Epidemiology Department, Cambridge, MA, USA
| | - Kourtney J. Davis
- Global Epidemiology, Janssen Pharmaceuticals, Titusville, NJ instead of Swarthmore, USA
| | - Nancy A. Dreyer
- Center for Advanced Evidence Generation, IQVIA, Durham, NC, USA
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28
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Giacomelli R, Afeltra A, Alunno A, Bartoloni-Bocci E, Berardicurti O, Bombardieri M, Bortoluzzi A, Caporali R, Caso F, Cervera R, Chimenti MS, Cipriani P, Coloma E, Conti F, D'Angelo S, De Vita S, Di Bartolomeo S, Distler O, Doria A, Feist E, Fisher BA, Gerosa M, Gilio M, Guggino G, Liakouli V, Margiotta DPE, Meroni P, Moroncini G, Perosa F, Prete M, Priori R, Rebuffi C, Ruscitti P, Scarpa R, Shoenfeld Y, Todoerti M, Ursini F, Valesini G, Vettori S, Vitali C, Tzioufas AG. Guidelines for biomarkers in autoimmune rheumatic diseases - evidence based analysis. Autoimmun Rev 2019; 18:93-106. [PMID: 30408582 DOI: 10.1016/j.autrev.2018.08.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/11/2018] [Indexed: 12/21/2022]
Abstract
Autoimmune rheumatic diseases are characterised by an abnormal immune system response, complement activation, cytokines dysregulation and inflammation. In last years, despite many progresses in managing these patients, it has been shown that clinical remission is reached in less than 50% of patients and a personalised and tailored therapeutic approach is still lacking resulting in a significant gap between guidelines and real-world practice. In this context, the need for biomarkers facilitating early diagnosis and profiling those individuals at the highest risk for a poor outcome has become of crucial interest. A biomarker generally refers to a measured characteristic which may be used as an indicator of some biological state or condition. Three different types of medical biomarkers has been suggested: i. mechanistic markers; ii. clinical disease markers; iii. therapeutic markers. A combination of biomarkers from these different groups could be used for an ideal more accurate diagnosis and treatment. However, although a growing body of evidence is focused on improving biomarkers, a significant amount of this information is not integrated on standard clinical care. The overarching aim of this work was to clarify the meaning of specific biomarkers during autoimmune diseases; their possible role in confirming diagnosis, predicting outcome and suggesting specific treatments.
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Affiliation(s)
- Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100 L'Aquila, Italy.
| | - Antonella Afeltra
- Department of Medicine, Unit of Allergology, Immunology, Rheumatology, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | | | - Onorina Berardicurti
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100 L'Aquila, Italy
| | - Michele Bombardieri
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Alessandra Bortoluzzi
- Department of Medical Science, Section of Rheumatology, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Cona, Ferrara, Italy
| | - Roberto Caporali
- IRCCS Policlinico San Matteo Foundation, Division of Rheumatology, University of Pavia, Pavia, Italy
| | - Francesco Caso
- Department of Clinical Medicine and Surgery, Rheumatology Unit, University of Naples Federico II, Naples, Italy
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Maria Sole Chimenti
- Department of Medicina dei Sistemi, Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100 L'Aquila, Italy
| | - Emmanuel Coloma
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Fabrizio Conti
- Department of Internal Medicine and Medical Specialties, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Salvatore D'Angelo
- PhD Scholarship in Life Sciences, Department of Health Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Salvatore De Vita
- Department of Medical and Biological Sciences, Rheumatology Clinic, Azienda Ospedaliero Universitaria S. Maria della Misericordia, University of Udine, Udine, Italy
| | - Salvatore Di Bartolomeo
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100 L'Aquila, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Eugen Feist
- Department of Rheumatology and Clinical Immunology of the Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Benjamin A Fisher
- Rheumatology Research Group and Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence (RACE), University of Birmingham, Birmingham, UK; Department of Rheumatology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Maria Gerosa
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Michele Gilio
- PhD Scholarship in Life Sciences, Department of Health Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Giuliana Guggino
- Dipartimento Biomedico di Medicina Interna e Specialistica, Rheumatology section, University of Palermo, Italy
| | - Vasiliki Liakouli
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100 L'Aquila, Italy
| | - Domenico Paolo Emanuele Margiotta
- Department of Medicine, Unit of Allergology, Immunology, Rheumatology, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Pierluigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Gianluca Moroncini
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Federico Perosa
- Department of Biomedical Sciences and Human Oncology (DIMO), Systemic Rheumatic and Autoimmune Diseases Unit, University of Bari Medical School, Bari, Italy
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology (DIMO), Systemic Rheumatic and Autoimmune Diseases Unit, University of Bari Medical School, Bari, Italy
| | - Roberta Priori
- Department of Internal Medicine and Medical Specialties, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Chiara Rebuffi
- Grant Office and Scientific Documentation Center, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100 L'Aquila, Italy
| | - Raffaele Scarpa
- Department of Clinical Medicine and Surgery, Rheumatology Unit, University of Naples Federico II, Naples, Italy
| | - Yehuda Shoenfeld
- Zabludowitz Centre for Autoimmune Diseases, Sheba Medical Centre, Tel-Hashomer, Israel
| | - Monica Todoerti
- IRCCS Policlinico San Matteo Foundation, Division of Rheumatology, University of Pavia, Pavia, Italy
| | - Francesco Ursini
- Department of Health Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Guido Valesini
- Department of Internal Medicine and Medical Specialties, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Serena Vettori
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Athanasios G Tzioufas
- Pathophysiology Department, General Hospital of Athens "Laiko", Medical School, National and Kapodistrian University of Athens, Greece
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Gamerman V, Cai T, Elsäßer A. Pragmatic randomized clinical trials: best practices and statistical guidance. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2018. [DOI: 10.1007/s10742-018-0192-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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