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Defelippe VM, Brilstra EH, Otte WM, Cross HJ, O'Callaghan F, De Giorgis V, Poduri A, Lerche H, Sisodiya S, Braun KPJ, Jansen FE, Perucca E. N-of-1 trials in epilepsy: A systematic review and lessons paving the way forward. Epilepsia 2024. [PMID: 39254637 DOI: 10.1111/epi.18068] [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: 02/15/2024] [Revised: 06/28/2024] [Accepted: 07/10/2024] [Indexed: 09/11/2024]
Abstract
OBJECTIVE Defined as prospective single-patient crossover studies with repeated paired cycles of active and control intervention, N-of-1 trials have gained attention as an option to obtain high-quality evidence of efficacy, particularly for patients with rare epilepsies in whom conduction of well-powered randomized controlled trials can be challenging. The objective of this systematic review is to provide an appraisal of the literature on N-of-1 trials in individuals with epilepsy. METHODS We searched PubMed and Embase on January 12, 2024, for studies meeting the following criteria: prospectively planned, within-patient, multiple-crossover design in individuals with epilepsy and outcomes related to comorbidities. Information on design, outcome measurements, intervention, and analyses was retrieved. Risk of bias assessment was performed using the Risk of Bias in N-of-1 Trials (RoBiNT) scale. We highlighted methodological aspects of the N-of-1 trials identified and discuss future recommendations. RESULTS Five studies met our inclusion criteria. An additional multiple-crossover trial that evaluated treatment effects exclusively at group level was also included because of its relevance to N-of-1 study methodology. The studies enrolled individuals with focal seizures, absences or cognitive impairement and electrographic discharges. Treatments included established or investigational antiseizure medications, off-label medications, neurostimulation or lifestyle intervention. Three of the five N-of-1 trials reported on individual cases. The studies' strengths were the use of individualized treatment dosages and symptom-specific patient-reported outcomes. Limitations were related to minimal reporting of baseline characteristics and seizure burden. SIGNIFICANCE The trials identified by our search exemplify how the N-of-1 design can be applied to assess interventions in individuals with epilepsy-related disorders. Future N-of-1 trials of antiseizure interventions should take into account baseline seizure frequency, should apply statistical models suited to capture seizure frequency changes reliably and make predefined interim assessments. Non-seizure outcome measures evaluable over short periods should be considered. Tailored N-of-1 methodology could pave the way to evidence-based, treatment selection for patients with rare epilepsies.
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Affiliation(s)
- Victoria M Defelippe
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Eva H Brilstra
- Department of Genetics, UMCU Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Willem M Otte
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Helen J Cross
- Developmental Neurosciences, University College London (UCL) Great Ormond Street NIHR BRC, Institute of Child Health, London, UK
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Finbar O'Callaghan
- Developmental Neurosciences, University College London (UCL) Great Ormond Street NIHR BRC, Institute of Child Health, London, UK
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Valentina De Giorgis
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
- Fondazione Mondino National Institute of Neurology/University of Pavia, Pavia, Italy
| | - Annapurna Poduri
- Epilepsy Genetics Program, Boston Children's Hospital and Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Holger Lerche
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University and University Hospital of Tübingen, Tubingen, Germany
| | - Sanjay Sisodiya
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
- Department of Clinical and Experimental Epilepsy, UCL Queen's Square Institute of Neurology, London, UK
| | - Kees P J Braun
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Floor E Jansen
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
| | - Emilio Perucca
- (Affiliated) member or collaborating partner of the European Reference Network (ERN) for rare and complex epilepsies (EpiCARE), Barcelona, Spain
- Department of Medicine, University of Melbourne (Austin Health), Heidelberg, Victoria, Australia
- Australia and Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
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Robbins-Welty GA, Chammas D, Silverman EJ, Lowry MF, Hale E, Martinez C, Nakatani MM, Shalev D, Noufi P, Riordan PA, Brenner KO, Rosa WE, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Diagnosing, Categorizing, and Addressing Fatigue. J Palliat Med 2024. [PMID: 39052494 DOI: 10.1089/jpm.2024.0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
Fatigue is a multifactorial symptom that is commonly faced by patients with cancer, chronic disease, and other serious illnesses. Fatigue causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a consortium of professionals across cancer care, physical therapy, exercise, pharmacy, psychiatry, and palliative medicine offers tips and insights on evaluating, categorizing, and addressing fatigue in the setting of serious illness. The comprehensive approach to managing fatigue underscores the importance of collaborative efforts characteristic of interdisciplinary palliative care. Prioritizing screening, diagnosing, and treating fatigue is crucial for enhancing patients' and families' overall quality of life.
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Affiliation(s)
- Gregg A Robbins-Welty
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Danielle Chammas
- Division of Palliative Medicine, Departments of Medicine and Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Ethan J Silverman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maria Felton Lowry
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Hale
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Corina Martinez
- Department of Physical Therapy, Duke University School of Physical Therapy, Durham, North Carolina, USA
| | - Morgan M Nakatani
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Shalev
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Paul Noufi
- Division of Palliative Medicine, Department of Medicine, MedStar Health, Georgetown University School of Medicine, Baltimore, Maryland, USA
| | - Paul A Riordan
- Department of Veterans Affairs, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Keri O Brenner
- Section of Palliative Care, Department of Medicine, School of Medicine, Stanford University, Palo Alto, California, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Chin-Yee N, Yennurajalingam S, Zimmermann C. Putting Methylphenidate for Cancer-Related Fatigue to Rest? J Clin Oncol 2024; 42:2363-2366. [PMID: 38771985 DOI: 10.1200/jco.24.00707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/23/2024] Open
Affiliation(s)
- Nicolas Chin-Yee
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada
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Almerud A, Frisk G, Klasson C, Björkhem-Bergman L. Methylphenidate for treating fatigue in palliative cancer care - effect and side effects in real-world data from a palliative care unit. Acta Oncol 2024; 63:9-16. [PMID: 38348853 PMCID: PMC11332525 DOI: 10.2340/1651-226x.2024.24156] [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: 10/22/2023] [Accepted: 12/22/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Methylphenidate can be used for the treatment of cancer-related fatigue (CRF), although randomized controlled trials have shown conflicting results. The aim of this study was to use 'real-world' data to evaluate the effect and side effects of using methylphenidate in palliative cancer care with a focus on the late palliative phase and dose-response. METHOD A retrospective review of medical records from a palliative care unit in Sweden was performed to evaluate the effect and adverse events (AEs) of using methylphenidate to treat CRF. Univariable and multivariable regression was performed and odds ratio (OR) calculated. Adjustments were made for sex, age, cancer type, dose and starting treatment <4 weeks before death. RESULTS Of the 2,419 screened patients, 112 had been treated with methylphenidate for CRF. The treatment was assessed as being effective in 51 patients (46%). Twenty-six patients (23%) experienced AEs that were generally mild, including anxiety, palpitations, and insomnia. Patients starting the treatment <4 weeks before death (n = 54) were less likely to have an effect from treatment compared to those starting earlier; adjusted OR 0.24 (95% CI 0.10-0.55). Doses of 20 mg and above were well-tolerated and had a higher frequency of effect in the crude data but not after adjustment for confounding factors. CONCLUSION Methylphenidate is generally effective and well-tolerated for the treatment of CRF in palliative care. However, patients with a short life expectancy (<4 weeks) seem to benefit less from the treatment regardless of age, cancer type and dose.
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Affiliation(s)
- Agneta Almerud
- ASIH Stockholm Södra, Palliative Home Care and Specialized Palliative Ward, Bergtallsvägen 12, SE-125 59 Älvsjö, Sweden
| | - Gabriella Frisk
- ASIH Stockholm Södra, Palliative Home Care and Specialized Palliative Ward, Bergtallsvägen 12, SE-125 59 Älvsjö, Sweden; Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo floor 7, SE-141 83, Huddinge, Sweden
| | - Caritha Klasson
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo floor 7, SE-141 83, Huddinge, Sweden
| | - Linda Björkhem-Bergman
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo floor 7, SE-141 83, Huddinge, Sweden; Stockholms Sjukhem, Palliative Medicine, Mariebergsgatan 22, SE-112 19, Stockholm, Sweden.
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5
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Müller AR, den Hollander B, van de Ven PM, Roes KCB, Geertjens L, Bruining H, van Karnebeek CDM, Jansen FE, de Wit MCY, Ten Hoopen LW, Rietman AB, Dierckx B, Wijburg FA, Boot E, Brands MMG, van Eeghen AM. Cannabidiol (Epidyolex®) for severe behavioral manifestations in patients with tuberous sclerosis complex, mucopolysaccharidosis type III and fragile X syndrome: protocol for a series of randomized, placebo-controlled N-of-1 trials. BMC Psychiatry 2024; 24:23. [PMID: 38177999 PMCID: PMC10768432 DOI: 10.1186/s12888-023-05422-3] [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: 07/27/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Many rare genetic neurodevelopmental disorders (RGNDs) are characterized by intellectual disability (ID), severe cognitive and behavioral impairments, potentially diagnosed as a comorbid autism spectrum disorder or attention-deficit hyperactivity disorder. Quality of life is often impaired due to irritability, aggression and self-injurious behavior, generally refractory to standard therapies. There are indications from previous (case) studies and patient reporting that cannabidiol (CBD) may be an effective treatment for severe behavioral manifestations in RGNDs. However, clear evidence is lacking and interventional research is challenging due to the rarity as well as the heterogeneity within and between disease groups and interindividual differences in treatment response. Our objective is to examine the effectiveness of CBD on severe behavioral manifestations in three RGNDs, including Tuberous Sclerosis Complex (TSC), mucopolysaccharidosis type III (MPS III), and Fragile X syndrome (FXS), using an innovative trial design. METHODS We aim to conduct placebo-controlled, double-blind, block-randomized, multiple crossover N-of-1 studies with oral CBD (twice daily) in 30 patients (aged ≥ 6 years) with confirmed TSC, MPS III or FXS and severe behavioral manifestations. The treatment is oral CBD up to a maximum of 25 mg/kg/day, twice daily. The primary outcome measure is the subscale irritability of the Aberrant Behavior Checklist. Secondary outcome measures include (personalized) patient-reported outcome measures with regard to behavioral and psychiatric outcomes, disease-specific outcome measures, parental stress, seizure frequency, and adverse effects of CBD. Questionnaires will be completed and study medication will be taken at the participants' natural setting. Individual treatment effects will be determined based on summary statistics. A mixed model analysis will be applied for analyzing the effectiveness of the intervention per disorder and across disorders combining data from the individual N-of-1 trials. DISCUSSION These N-of-1 trials address an unmet medical need and will provide information on the effectiveness of CBD for severe behavioral manifestations in RGNDs, potentially generating generalizable knowledge at an individual-, disorder- and RGND population level. TRIAL REGISTRATION EudraCT: 2021-003250-23, registered 25 August 2022, https://www.clinicaltrialsregister.eu/ctr-search/trial/2021-003250-23/NL .
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Affiliation(s)
- A R Müller
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - B den Hollander
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Geertjens
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
| | - H Bruining
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
- Levvel, Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - C D M van Karnebeek
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
- Department of Human Genetics, Amsterdam UMC, Amsterdam, The Netherlands
| | - F E Jansen
- Department of Pediatric Neurology, Brain, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Y de Wit
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L W Ten Hoopen
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A B Rietman
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B Dierckx
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - E Boot
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- The Dalglish Family 22Q Clinic, Toronto, ON, Canada
- Department of Psychiatry & Neuropsychology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M M G Brands
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - A M van Eeghen
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- 's Heeren Loo Care Group, Amersfoort, The Netherlands.
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands.
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Zoh RS, Esteves BH, Yu X, Fairchild AJ, Vazquez AI, Chapple AG, Brown AW, George B, Gordon D, Landsittel D, Gadbury GL, Pavela G, de Los Campos G, Mestre LM, Allison DB. Design, analysis, and interpretation of treatment response heterogeneity in personalized nutrition and obesity treatment research. Obes Rev 2023; 24:e13635. [PMID: 37667550 PMCID: PMC10825777 DOI: 10.1111/obr.13635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 03/29/2023] [Accepted: 07/24/2023] [Indexed: 09/06/2023]
Abstract
It is increasingly assumed that there is no one-size-fits-all approach to dietary recommendations for the management and treatment of chronic diseases such as obesity. This phenomenon that not all individuals respond uniformly to a given treatment has become an area of research interest given the rise of personalized and precision medicine. To conduct, interpret, and disseminate this research rigorously and with scientific accuracy, however, requires an understanding of treatment response heterogeneity. Here, we define treatment response heterogeneity as it relates to clinical trials, provide statistical guidance for measuring treatment response heterogeneity, and highlight study designs that can quantify treatment response heterogeneity in nutrition and obesity research. Our goal is to educate nutrition and obesity researchers in how to correctly identify and consider treatment response heterogeneity when analyzing data and interpreting results, leading to rigorous and accurate advancements in the field of personalized medicine.
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Affiliation(s)
- Roger S Zoh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | | | - Xiaoxin Yu
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - Amanda J Fairchild
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Ana I Vazquez
- Department of Epidemiology and Biostatistics, Michigan State University, Lansing, Michigan, USA
| | - Andrew G Chapple
- Biostatistics Program, School of Public Health, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Andrew W Brown
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - Brandon George
- College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Derek Gordon
- Department of Genetics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - Gary L Gadbury
- Department of Statistics, Kansas State University, Manhattan, Kansa, USA
| | - Greg Pavela
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gustavo de Los Campos
- Departments of Epidemiology & Biostatistics and Statistics & Probability, IQ - Institute for Quantitative Health Science and Engineering, Michigan State University, Lansing, Michigan, USA
| | - Luis M Mestre
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - David B Allison
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
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Müller A, Konigorski S, Meißner C, Fadai T, Warren CV, Falkenberg I, Kircher T, Nestoriuc Y. Study protocol: combined N-of-1 trials to assess open-label placebo treatment for antidepressant discontinuation symptoms [FAB-study]. BMC Psychiatry 2023; 23:749. [PMID: 37833651 PMCID: PMC10576328 DOI: 10.1186/s12888-023-05184-y] [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: 08/17/2023] [Accepted: 09/12/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Antidepressant discontinuation is associated with a broad range of adverse effects. Debilitating discontinuation symptoms can impede the discontinuation process and contribute to unnecessary long-term use of antidepressants. Antidepressant trials reveal large placebo effects, indicating a potential use of open-label placebo (OLP) treatment to facilitate the discontinuation process. We aim to determine the effect of OLP treatment in reducing antidepressant discontinuation symptoms using a series of N-of-1 trials. METHODS A series of randomized, single-blinded N-of-1 trials will be conducted in 20 patients with fully remitted DSM-V major depressive disorder, experiencing moderate to severe discontinuation symptoms following antidepressant discontinuation. Each N-of-1 trial consists of two cycles, each comprising two-week alternating periods of OLP treatment and of no treatment in a random order, for a total of eight weeks. Our primary outcome will be self-reported discontinuation symptoms rated twice daily via the smartphone application 'StudyU'. Secondary outcomes include expectations about discontinuation symptoms and (depressed) mood. Statistical analyses will be based on a Bayesian multi-level random effects model, reporting posterior estimates of the overall and individual treatment effects. DISCUSSION Results of this trial will provide insight into the clinical application of OLP in treating antidepressant discontinuation symptoms, potentially offering a new cost-effective therapeutic tool. This trial will also determine the feasibility and applicability of a series of N-of-1 trials in a clinical discontinuation trial. TRIAL REGISTRATION ClinicalTrials.gov: NCT05051995, first registered September 20, 2021.
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Affiliation(s)
- Amke Müller
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany.
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Stefan Konigorski
- Digital Health - Machine Learning Group, Hasso-Plattner-Institute for Digital Engineering, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Statistics, Harvard University, 150 Western Ave, Boston, MA, 02134, USA
| | - Carina Meißner
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Tahmine Fadai
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Claire V Warren
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Irina Falkenberg
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Yvonne Nestoriuc
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Butler M, D'Angelo S, Ahn H, Chandereng T, Miller D, Perrin A, Romain AMN, Scatoni A, Friel CP, Cheung YK, Davidson KW. A Series of Personalized Virtual Light Therapy Interventions for Fatigue: Feasibility Randomized Crossover Trial for N-of-1 Treatment. JMIR Form Res 2023; 7:e45510. [PMID: 37721795 PMCID: PMC10546268 DOI: 10.2196/45510] [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: 01/09/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Fatigue is one of the most common symptoms treated in primary care and can lead to deficits in mental health and functioning. Light therapy can be an effective treatment for symptoms of fatigue; however, the feasibility, scalability, and individual-level heterogeneity of light therapy for fatigue are unknown. OBJECTIVE This study aimed to evaluate the feasibility, acceptability, and effectiveness of a series of personalized (N-of-1) interventions for the virtual delivery of bright light (BL) therapy and dim light (DL) therapy versus usual care (UC) treatment for fatigue in 60 participants. METHODS Participants completed satisfaction surveys comprising the System Usability Scale (SUS) and items assessing satisfaction with the components of the personalized trial. Symptoms of fatigue were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) daily, PROMIS weekly, and ecological momentary assessment (EMA) questionnaires delivered 3 times daily. Comparisons of fatigue between the BL, DL, and UC treatment periods were conducted using generalized linear mixed model analyses between participants and generalized least squares analyses within individual participants. RESULTS Participants rated the usability of the personalized trial as acceptable (average SUS score=78.9, SD 15.6), and 92% (49/53) of those who completed satisfaction surveys stated that they would recommend the trial to others. The levels of fatigue symptoms measured using the PROMIS daily fatigue measure were lower or improved in the BL (B=-1.63, 95% CI -2.63 to -0.63) and DL (B=-1.44, 95% CI -2.50 to -0.38) periods relative to UC. The treatment effects of BL and DL on the PROMIS daily measure varied among participants. Similar findings were demonstrated for the PROMIS weekly and EMA measures of fatigue symptoms. CONCLUSIONS The participant scores on the SUS and satisfaction surveys suggest that personalized N-of-1 trials of light therapy for fatigue symptoms are both feasible and acceptable. Both interventions produced significant (P<.05) reductions in participant-reported PROMIS and EMA fatigue symptoms relative to UC. However, the heterogeneity of these treatment effects across participants indicated that the effect of light therapy was not uniform. This heterogeneity along with high ratings of usability and satisfaction support the use of personalized N-of-1 research designs in evaluating the effect of light therapy on fatigue for each patient. Furthermore, the results of this trial provide additional support for the use of a series of personalized N-of-1 research trials. TRIAL REGISTRATION ClinicalTrials.gov NCT04707846; https://clinicaltrials.gov/ct2/show/NCT04707846.
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Affiliation(s)
- Mark Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Stefani D'Angelo
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Heejoon Ahn
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Thevaa Chandereng
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Danielle Miller
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Alexandra Perrin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Anne-Marie N Romain
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, United States
| | - Ava Scatoni
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Ciaran P Friel
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Ying-Kuen Cheung
- Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Karina W Davidson
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, United States
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9
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Müller AR, Zinkstok JR, Rommelse NNJ, van de Ven PM, Roes KCB, Wijburg FA, de Rooij-Askes E, Linders C, Boot E, van Eeghen AM. Methylphenidate for attention-deficit/hyperactivity disorder in patients with Smith-Magenis syndrome: protocol for a series of N-of-1 trials. Orphanet J Rare Dis 2021; 16:380. [PMID: 34496899 PMCID: PMC8424817 DOI: 10.1186/s13023-021-02003-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background Smith–Magenis syndrome (SMS) is a rare genetic neurodevelopmental disorder characterized by intellectual disability and severe behavioural and sleep disturbances. Often, patients with SMS are diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the effectiveness of methylphenidate (MPH), the first-line pharmacological treatment for ADHD, in patients with SMS is unclear. Our objective is to examine the effectiveness of MPH for ADHD symptoms in individuals with SMS, proposing an alternative trial design as traditional randomized controlled trials are complex in these rare and heterogeneous patient populations. Methods and analysis We will initiate an N-of-1 series of double-blind randomized and placebo-controlled multiple crossover trials in six patients aged ≥ 6 years with a genetically confirmed SMS diagnosis and a multidisciplinary established ADHD diagnosis, according to a power analysis based on a summary measures analysis of the treatment effect. Each N-of-1 trial consists of a baseline period, dose titration phase, three cycles each including randomized intervention, placebo and washout periods, and follow-up. The intervention includes twice daily MPH (doses based on age and body weight). The primary outcome measure will be the subscale hyperactivity/inattention of the Strengths and Difficulties Questionnaire (SDQ), rated daily. Secondary outcome measures are the shortened version of the Emotion Dysregulation Inventory (EDI) reactivity index, Goal Attainment Scaling (GAS), and the personal questionnaire (PQ). Statistical analysis will include a mixed model analysis. All subjects will receive an assessment of their individual treatment effect and data will be aggregated to investigate the effectiveness of MPH for ADHD in SMS at a population level. Conclusions This study will provide information on the effectiveness of MPH for ADHD in SMS, incorporating personalized outcome measures. This protocol presents the first properly powered N-of-1 study in a rare genetic neurodevelopmental disorder, providing a much-needed bridge between science and practice to optimize evidence-based and personalized care. Trial registration This study is registered in the Netherlands Trial Register (NTR9125).
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Affiliation(s)
- A R Müller
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J R Zinkstok
- Department of Psychiatry and Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N N J Rommelse
- Karakter, Child and Adolescent Psychiatry, Nijmegen, The Netherlands.,Department of Psychiatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - C Linders
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands
| | - E Boot
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada
| | - A M van Eeghen
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands. .,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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10
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Nikles J, Onghena P, Vlaeyen JW, Wicksell RK, Simons LE, McGree JM, McDonald S. Establishment of an International Collaborative Network for N-of-1 Trials and Single-Case Designs. Contemp Clin Trials Commun 2021; 23:100826. [PMID: 34401597 PMCID: PMC8350373 DOI: 10.1016/j.conctc.2021.100826] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
In this article we briefly examine the unique features of Single-Case Designs (SCDs) (studies in a single participant), their history and current trends, and real-world clinical applications. The International Collaborative Network for N-of-1 Trials and Single-Case Designs (ICN) is a formal collaborative network for individuals with an interest in SCDs. The ICN was established in 2017 to support the SCD scientific community and provide opportunities for collaboration, a global communication channel, resource sharing and knowledge exchange. In May 2021, there were more than 420 members in 31 countries. A member survey was undertaken in 2019 to identify priorities for the ICN for the following few years. This article outlines the key priorities identified and the ICN's progress to date in these key areas including network activities (developing a communications strategy to increase awareness, collecting/sharing a comprehensive set of resources, guidelines and tips, and incorporating the consumer perspective) and scientific activities (writing position papers and guest editing special journal issues, exploring key stakeholder perspectives about SCDs, and working to streamline ethical approval processes for SCDs). The ICN provides a practical means to engage with this methodology through membership. We encourage clinicians, researchers, industry, and healthcare consumers to learn more about and conduct SCDs, and to join us in our mission of using SCDs to improve health outcomes for individuals and populations.
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Affiliation(s)
- Jane Nikles
- Centre for Clinical Research, The University of Queensland, Australia
| | | | | | | | | | | | - Suzanne McDonald
- Centre for Clinical Research, The University of Queensland, Australia
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11
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Mitchell G. Rational prescribing in community palliative care. Aust Prescr 2021; 44:45-48. [PMID: 33911331 PMCID: PMC8075750 DOI: 10.18773/austprescr.2021.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Palliative care is the province of everyone, particularly people managing older patients. Most people die of multimorbidity, frailty and dementia rather than cancer and will never see a palliative care specialist. People dying from non-malignant disease have symptoms and problems that are usually predictable. Common symptoms like pain and dyspnoea can be anticipated. Planning to prevent them, or for when they occur, is more effective than waiting until they happen. Deprescribing is an effective way of preventing morbidity in this group. Getting to know a few medicines well for each symptom is important when providing palliative care for patients. Starting at low doses and increasing slowly is also key.
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12
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Müller AR, Brands MMMG, van de Ven PM, Roes KCB, Cornel MC, van Karnebeek CDM, Wijburg FA, Daams JG, Boot E, van Eeghen AM. Systematic Review of N-of-1 Studies in Rare Genetic Neurodevelopmental Disorders: The Power of 1. Neurology 2021; 96:529-540. [PMID: 33504638 PMCID: PMC8032375 DOI: 10.1212/wnl.0000000000011597] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To improve the use of N-of-1 studies in rare genetic neurodevelopmental disorders, we systematically reviewed the literature and formulated recommendations for future studies. METHODS The systematic review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42020154720). EMBASE and MEDLINE were searched for relevant studies. Information was recorded on types of interventions, outcome measures, validity, strengths, and limitations using standard reporting guidelines and critical appraisal tools. Qualitative and descriptive analyses were performed. RESULTS Twelve studies met the N-of-1 inclusion criteria, including both single trials and series. Interventions were mainly directed to neuropsychiatric manifestations. Main strengths were the use of personalized and clinically relevant outcomes in most studies. Generalizability was compromised due to limited use of validated and generalizable outcome measures. CONCLUSION N-of-1 studies are sporadically reported in rare genetic neurodevelopmental disorders. Properly executed N-of-1 studies may provide a powerful alternative to larger randomized controlled trials in rare disorders and a much needed bridge between practice and science. We provide recommendations for future N-of-1 studies in rare genetic neurodevelopmental disorders, ultimately optimizing evidence-based and personalized care.
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Affiliation(s)
- Annelieke R Müller
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Marion M M G Brands
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Peter M van de Ven
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Kit C B Roes
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Martina C Cornel
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Clara D M van Karnebeek
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Frits A Wijburg
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Joost G Daams
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Erik Boot
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Agnies M van Eeghen
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands.
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Fatigue in Cancer Patients in Palliative Care-A Review on Pharmacological Interventions. Cancers (Basel) 2021; 13:cancers13050985. [PMID: 33652866 PMCID: PMC7956665 DOI: 10.3390/cancers13050985] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Cancer related fatigue is a common and distressing symptom for patients with cancer during and after primary treatment, and also in the palliative phase of the disease trajectory. This review focuses on the pharmacological treatment of cancer related fatigue in patients with advanced or metastatic cancer. There are few high-quality studies performed in this setting, but both methylphenidate and corticosteroids might be used to relieve fatigue. Abstract Fatigue is one of the most distressing symptoms experienced by cancer patients. The suggested biological mechanism for cancer related fatigue (CRF) includes immune activation triggered by tumor tissue or by anticancer treatment but other mechanisms have also been proposed. Previous large meta-analysis of interventions on fatigue focuses mostly on patients early in the disease trajectory, with only one tenth of included studies performed in palliative cohorts. The aim of this narrative review is therefore to present a background on CRF with focus on the palliative setting. A summary of recent randomized, controlled trials on pharmacological interventions on CRF in palliative care is presented, including studies on psychostimulants, corticosteroids, testosterone and melatonin. Interestingly, in several of these studies there was a positive and similar effect on fatigue in both the intervention and the placebo arm—indicating an important placebo effect for any pharmacological treatment. In addition, studies on dietary supplements and on pharmacological complementary medicines are discussed. To conclude, the evidence is still weak for using pharmacological treatments on CRF in palliative care patients—although methylphenidate and corticosteroids might be considered.
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Pedersen L, Lund L, Petersen MA, Sjogren P, Groenvold M. Methylphenidate as Needed for Fatigue in Patients With Advanced Cancer. A Prospective, Double-Blind, and Placebo-Controlled Study. J Pain Symptom Manage 2020; 60:992-1002. [PMID: 32464260 DOI: 10.1016/j.jpainsymman.2020.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 11/12/2022]
Abstract
CONTEXT Cancer-related fatigue is a highly prevalent symptom with a strong negative impact on patients' daily life. OBJECTIVES To evaluate the efficacy of methylphenidate as needed for the management of fatigue in patients with advanced cancer. METHODS A prospective, controlled, double-blind, and paired design, where the patient was her and/or his own control. Patients with advanced cancer with a tiredness score of ≥50 on a 0-100 visual analogue scale (VAS) were included. Patients were given 10 placebo and 10 methylphenidate tablets numbered 1-20 packed in blocks of four with two active and two placebo tablets (randomly arranged). Patients taking minimum three tablets were regarded evaluable. Primary effect parameters were mean differences in VAS for tiredness after two and five hours. With 28 evaluable patients, the study had a power of 0.90 to detect a mean difference of 15 between active and placebo. RESULTS Thirty-eight patients were enrolled to get 28 evaluable patients. Mean tiredness score before taking the tablets was 75 for placebo and 72 for methylphenidate on VAS (0-100). Mean changes (decrease) for methylphenidate after two and five hours were 20 and 17, respectively, and eight and five for placebo. Comparing mean differences, a significant decrease for methylphenidate compared with placebo was observed after two hours (P = 0.004) and five hours (P = 0.001), respectively. CONCLUSION In this controlled and double-blind study in patients with advanced cancer, methylphenidate as needed was significantly more effective than placebo in relieving fatigue after two and five hours.
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Affiliation(s)
- Lise Pedersen
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Line Lund
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Morten A Petersen
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Per Sjogren
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Section of Palliative Medicine, Department of Oncology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - Mogens Groenvold
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark; Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Senarathne SGJ, Overstall AM, McGree JM. Bayesian adaptive N‐of‐1 trials for estimating population and individual treatment effects. Stat Med 2020; 39:4499-4518. [DOI: 10.1002/sim.8737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 07/18/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022]
Affiliation(s)
| | - Antony M. Overstall
- Southampton Statistical Sciences Research Institute University of Southampton Southampton UK
| | - James M. McGree
- School of Mathematical Sciences Queensland University of Technology Brisbane Queensland Australia
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Fabi A, Bhargava R, Fatigoni S, Guglielmo M, Horneber M, Roila F, Weis J, Jordan K, Ripamonti CI. Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment. Ann Oncol 2020; 31:713-723. [PMID: 32173483 DOI: 10.1016/j.annonc.2020.02.016] [Citation(s) in RCA: 204] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/27/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
- A Fabi
- Division of Medical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - R Bhargava
- William Osler Health System, Corporate Department of Research, Department of Oncology and Division of Palliative Care, Brampton, Canada
| | - S Fatigoni
- Division of Medical Oncology, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - M Guglielmo
- Oncology-Supportive Care Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - M Horneber
- Department of Internal Medicine, Division of Oncology and Hematology & Division of Pneumology, Paracelsus Medical University, Klinikum, Nuremberg, Germany
| | - F Roila
- Division of Medical Oncology, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - J Weis
- Department of Self Help Research in Oncology, Comprehensive Cancer Center, University Medical Center, Freiburg, Germany
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - C I Ripamonti
- Oncology-Supportive Care Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Currow DC, Agar MR, Phillips JL. Role of Hospice Care at the End of Life for People With Cancer. J Clin Oncol 2020; 38:937-943. [DOI: 10.1200/jco.18.02235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patient-defined factors that are important at the end of life include being physically independent for as long as possible, good symptom control, and spending quality time with friends and family. Hospice care adds to the quality of care and these patient-centered priorities for people with cancer and their families in the last weeks and days of life. Evidence from large observational studies demonstrate that hospice care can improve outcomes directly and support better and more appropriate health care use for people in the last stages of cancer. Team-based community hospice care has measurable benefits for patients, their family caregivers, and health services. In addition to improved symptom control for patients and a greater likelihood of time spent at home, caregiver outcomes are better when hospice care is accessed: informational needs are better met, and caregivers have an improved ability to move on with life after the patient’s death compared with people who did not have access to these services. Hospice care continues to evolve as its reach expands and the needs of patients continue to broaden. This is reflected in the transition from hospice being based on excellence in nursing to teams with a broad range of health professionals to meet the complex and changing needs of patients and their families. Additional integration of cancer services with hospice care will help to provide more seamless care for patients and supporting family caregivers during their caregiving and after the death of the patient.
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Affiliation(s)
- David C. Currow
- University of Technology Sydney, Ultimo, NSW, Australia
- University of Hull, Hull, United Kingdom
| | - Meera R. Agar
- University of Technology Sydney, Ultimo, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
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Bradbury J, Avila C, Grace S. Practice-Based Research in Complementary Medicine: Could N-of-1 Trials Become the New Gold Standard? Healthcare (Basel) 2020; 8:E15. [PMID: 31936355 PMCID: PMC7151123 DOI: 10.3390/healthcare8010015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/07/2020] [Indexed: 12/12/2022] Open
Abstract
Complementary medicines and therapies are popular forms of healthcare with a long history of traditional use. Yet, despite increasing consumer demand, there is an ongoing exclusion of complementary medicines from mainstream healthcare systems. A lack of evidence is often cited as justification. Until recently, high-quality evidence of treatment efficacy was defined as findings from well-conducted systematic reviews and meta-analyses of randomized controlled trials. In a recent and welcome move by the Oxford Centre for Evidence-Based Practice, however, the N-of-1 trial design has also been elevated to the highest level of evidence for treatment efficacy of an individual, placing this research design on par with the meta-analysis. N-of-1 trial designs are experimental research methods that can be implemented in clinical practice. They incorporate much of the rigor of group clinical trials, but are designed for individual patients. Individualizing treatment interventions and outcomes in research designs is consistent with the movement towards patient-centered care and aligns well with the principles of holism as practiced by naturopaths and many other complementary medicine practitioners. This paper explores whether rigorously designed and conducted N-of-1 trials could become a new 'gold standard' for demonstrating treatment efficacy for complementary medicine interventions in individual patients in clinical practice.
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Affiliation(s)
- Joanne Bradbury
- School of Health and Human Sciences, Southern Cross University, Gold Coast, QLD 4225, Australia
| | - Cathy Avila
- School of Health and Human Sciences, Southern Cross University, Lismore, NSW 2480, Australia; (C.A.); (S.G.)
| | - Sandra Grace
- School of Health and Human Sciences, Southern Cross University, Lismore, NSW 2480, Australia; (C.A.); (S.G.)
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Nikles J, Tate R, Mitchell G, Perdices M, McGree J, Freeman C, Jacob S, Taing M, Sterling M. Personalised treatments for acute whiplash injuries: A pilot study of nested N-of-1 trials in a multiple baseline single-case experimental design. Contemp Clin Trials Commun 2019; 16:100480. [PMID: 31763492 PMCID: PMC6859231 DOI: 10.1016/j.conctc.2019.100480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 10/20/2019] [Accepted: 10/24/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Whiplash associated disorder (WAD), a common and disabling condition, incurs huge burden and costs to Australia. Yet, current treatments for whiplash are not very effective; improved outcomes are urgently needed. Clinical guidelines recommend simple analgesia (paracetamol and non-steroidal anti-inflammatory drugs) but there have been no trials of guideline-recommended drugs. This study will investigate the effectiveness of evidence-based advice (EBA), paracetamol, naproxen, and both paracetamol and naproxen, in reducing daily neck pain and preventing chronic neck pain after whiplash injury. METHODS This study is a pilot series of multi-cycle, double-blinded, randomised N-of-1 trials, nested in a multiple baseline design. The design will comprise three baselines of 5, 8 or 11 days duration. Post enrolment, participants will be randomly assigned to one of the baselines. Fifteen participants with acute (<2 weeks) Grade II WAD, experiencing at least moderate pain (NRS: ≥ 5/10), and at risk of poor recovery will be recruited from hospitals in Queensland, Australia, and through local physiotherapists. Patients will receive EBA plus a randomised sequence of three cycles of ten day treatment triplets (paracetamol designated as a C phase, naproxen, designated as a D phase, and both paracetamol and naproxen, designated as an E phase). DISCUSSION We will test the effects of different treatments on the primary outcome of average neck pain intensity collected daily and at 4 and 7 months post-injury. Secondary outcomes, including disability, depression, post-traumatic stress symptoms, pain catastrophizing, and feasibility of study procedures, will also be evaluated. The results of this study will inform a larger trial aiming to strengthen the evidence on EBA and simple analgesics for WAD. TRIAL REGISTRATION Clinical Trials Primary Registry: Australian and New Zealand Clinical Trials Registry. CLINICAL TRIAL REGISTRATION NUMBER ACTRN12618001291279. DATE OF REGISTRATION 31/07/2018. PRIMARY TRIAL SPONSOR The University of Queensland, Brisbane QLD 4072 Australia. FUNDING The University of Queensland.
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Affiliation(s)
- J. Nikles
- Recover Injury Research Centre, The University of Queensland, Herston, QLD, Australia
- NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, Australia
| | - R.L. Tate
- John Walsh Centre for Rehabilitation Studies, Northern Clinical School, The University of Sydney, Sydney, Australia
| | - G. Mitchell
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- Limestone Medical Centre, Ipswich, QLD, Australia
| | - M. Perdices
- Royal North Shore Hospital, Sydney, Australia
| | - J.M. McGree
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - C. Freeman
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, QLD, Australia
| | - S. Jacob
- Recover Injury Research Centre, The University of Queensland, Herston, QLD, Australia
| | - M.W. Taing
- School of Pharmacy, The University of Queensland, QLD, Australia
| | - M. Sterling
- Recover Injury Research Centre, The University of Queensland, Herston, QLD, Australia
- NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, Australia
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Nikles J, O'Sullivan J, Mitchell G, Smith S, McGree J, Senior H, Dissanyaka N, Ritchie A. Protocol: Using N-of-1 tests to identify responders to melatonin for sleep disturbance in Parkinson's disease. Contemp Clin Trials Commun 2019; 15:100397. [PMID: 31338478 PMCID: PMC6626998 DOI: 10.1016/j.conctc.2019.100397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/05/2019] [Accepted: 06/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND 40% of Parkinson's Disease (PD) sufferers experience insomnia, impacting health and quality of life for patients and family members, especially carers. There is little evidence that current treatments are effective. OBJECTIVES To determine the effectiveness of melatonin in reducing insomnia in 44 individuals with PD using N-of-1 trials. To aggregate group data to arrive at population estimates of effectiveness (measured by improvements in PDSS-2) and safety (measured by adverse events) of melatonin in improving insomnia in PD. To assess the feasibility of offering N-of-1 trials for insomnia in PD. METHODOLOGY Participants will receive either immediate-release melatonin or placebo in random order in 3 paired two-week treatment periods (12 weeks total). Based on their response in a two-week run-in period on 3 mg daily, they will trial either 3 mg or 6 mg. Patients will keep daily sleep diaries and wear a MotionWatch throughout. After the trial patients will discuss their individual report with their doctor, which provides direct feedback about effectiveness and safety of melatonin for them. STATISTICAL METHODS We will analyse N-of-1 tests 1) individually: effects of melatonin on PDSS-2 and safety will be reported; and 2) aggregated across individual N-of-1 studies, combined using a Bayesian multilevel random effects model, which will account for repeated measures on individuals over time, and will return posterior estimates of overall treatment effect, and effect in each individual. CLINICAL TRIAL REGISTRATION NUMBER ACTRN12617001103358.
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Affiliation(s)
- J. Nikles
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - J.D. O'Sullivan
- Royal Brisbane & Women's Hospital (RBWH), Neurology Department, School of Medicine, St Andrew's, Wesley and RBWH Hospitals, The University of Queensland, Brisbane, Australia
| | - G.K. Mitchell
- General Practice and Palliative Care, School of Medicine, The University of Queensland, Brisbane, Australia
| | - S.S. Smith
- Institute for Social Science Research (ISSR), The University of Queensland, Brisbane, Australia
| | - J.M. McGree
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Australia
| | - H. Senior
- Human Biology and Health, College of Health, Massey University, Auckland, New Zealand
| | | | - A. Ritchie
- St Andrew's War Memorial Hospital, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Abstract
PURPOSE OF REVIEW Cancer-related fatigue (CRF) is a frequent and distressing symptom present at any stage of the disease. However, it is still underreported, rarely properly assessed and undertreated. RECENT FINDINGS There are international guidelines available, but also several barriers to their implementation into clinical practice. SUMMARY According to guidelines, all patients should be clinically screened for CRF on regular basis, at the initial cancer visit and at intervals during every clinic visit, also at posttreatment follow-up visits. Generally, any treatable contributing factors should be identified and possibly treated. After the concomitant factors have been improved or removed, pharmacological and or nonpharmacological treatments of CRF can be considered.Further research is needed to better understand the causes, the better treatments, the easier assessment tool for CRF for clinical practice and to identify barriers and facilitators to implementing CRF guidelines.
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Jerome RN, Pulley JM, Edwards TL, Dickerson AB, Conway D, Van Driest SL, Bernard GR, Harris PA. We're not all cut from the same cloth: TAILORing treatments for children with chronic conditions. J Patient Rep Outcomes 2019; 3:25. [PMID: 31037558 PMCID: PMC6488630 DOI: 10.1186/s41687-019-0117-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/16/2019] [Indexed: 12/04/2022] Open
Abstract
Background Finding the optimal treatment for a chronic condition can be a complex and lengthy endeavor for both the patient and the clinician. To address this challenge, we developed an “N-of-1” quality improvement infrastructure to aid providers and patients in personalized treatment decision-making using systematic assessment of patient-reported outcomes during routine care. Methods Using the REDCap data management infrastructure, we implemented three pediatric pilots of the Treatment Assessments in the Individual Leading to Optimal Regimens (TAILOR) tool, including children receiving early intervention, children with attention deficit hyperactivity disorder, and children with challenging behaviors in the classroom setting. This retrospective review of data summarizes utilization and satisfaction data during our pilot experience with the tool. Results The three pilots included a combined total of 109 children and 39 healthcare providers, with 67 parents and 77 teachers invited to share data using brief surveys administered using TAILOR. Overall survey response rates ranged from 38% to 84% across the three pilots, with response rates notably higher among teachers as compared with parents. Satisfaction data indicated positive impressions of the tool’s utility. Discussion These experiences show the utility of the TAILOR framework for supporting collection and incorporation of patient-reported outcomes into the care of individuals with chronic conditions.
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Affiliation(s)
- Rebecca N Jerome
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA.
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA
| | - Terri L Edwards
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA
| | - Alyssa B Dickerson
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA
| | - Douglas Conway
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, 2200 Children's Way, 8232 Doctors' Office Tower, Nashville, TN, 37232, USA
| | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA
| | - Paul A Harris
- Vanderbilt Institute for Clinical and Translational Research, 2525 West End Avenue, Suite 600, Nashville, Tennessee, 37203, USA
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Stunnenberg BC, Raaphorst J, Groenewoud HM, Statland JM, Griggs RC, Woertman W, Stegeman DF, Timmermans J, Trivedi J, Matthews E, Saris CGJ, Schouwenberg BJ, Drost G, van Engelen BGM, van der Wilt GJ. Effect of Mexiletine on Muscle Stiffness in Patients With Nondystrophic Myotonia Evaluated Using Aggregated N-of-1 Trials. JAMA 2018; 320:2344-2353. [PMID: 30535218 PMCID: PMC6583079 DOI: 10.1001/jama.2018.18020] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In rare diseases it is difficult to achieve high-quality evidence of treatment efficacy because of small cohorts and clinical heterogeneity. With emerging treatments for rare diseases, innovative trial designs are needed. OBJECTIVE To investigate the effectiveness of mexiletine in nondystrophic myotonia using an aggregated N-of-1 trials design and compare results between this innovative design and a previously conducted RCT. DESIGN, SETTING, AND PARTICIPANTS A series of aggregated, double-blind, randomized, placebo-controlled N-of-1-trials, performed in a single academic referral center. Thirty Dutch adult patients with genetically confirmed nondystrophic myotonia (38 patients screened) were enrolled between February 2014 and June 2015. Follow-up was completed in September 2016. INTERVENTIONS Mexiletine (600 mg daily) vs placebo during multiple treatment periods of 4 weeks. MAIN OUTCOMES AND MEASURES Reduction in daily-reported muscle stiffness on a scale of 1 to 9, with higher scores indicating more impairment. A Bayesian hierarchical model aggregated individual N-of-1 trial data to determine the posterior probability of reaching a clinically meaningful effect of a greater than 0.75-point difference. RESULTS Among 30 enrolled patients (mean age, 43.4 [SD, 15.24] years; 22% men; 19 CLCN1 and 11 SCN4A genotype), 27 completed the study and 3 dropped out (1 because of a serious adverse event). In 24 of the 27 completers, a clinically meaningful treatment effect was found. In the Bayesian hierarchical model, mexiletine resulted in a 100% posterior probability of reaching a clinically meaningful reduction in self-reported muscle stiffness for the nondystrophic myotonia group overall and the CLCN1 genotype subgroup and 93% posterior probability for the SCN4A genotype subgroup. In the total nondystrophic myotonia group, the median muscle stiffness score was 6.08 (interquartile range, 4.71-6.80) at baseline and was 2.50 (95% credible interval [CrI], 1.77-3.24) during the mexiletine period and 5.56 (95% CrI, 4.73-6.39) during the placebo period; difference in symptom score reduction, 3.06 (95% CrI, 1.96-4.15; n = 27) favoring mexiletine. The most common adverse event was gastrointestinal discomfort (21 mexiletine [70%], 1 placebo [3%]). One serious adverse event occurred (1 mexiletine [3%]; allergic skin reaction). Using frequentist reanalysis, mexiletine compared with placebo resulted in a mean reduction in daily-reported muscle stiffness of 3.12 (95% CI, 2.46-3.78), consistent with the previous RCT treatment effect of 2.69 (95% CI, 2.12-3.26). CONCLUSIONS AND RELEVANCE In a series of N-of-1 trials of mexiletine vs placebo in patients with nondystrophic myotonia, there was a reduction in mean daily-reported muscle stiffness that was consistent with the treatment effect in a previous randomized clinical trial. These findings support the efficacy of mexiletine for treatment of nondystrophic myotonia as well as the feasibility of N-of-1 trials for assessing interventions in some chronic rare diseases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02045667.
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Affiliation(s)
- Bas C. Stunnenberg
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost Raaphorst
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Hans M. Groenewoud
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Robert C. Griggs
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Willem Woertman
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dick F. Stegeman
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Janneke Timmermans
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jaya Trivedi
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas
| | - Emma Matthews
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Christiaan G. J. Saris
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas J. Schouwenberg
- Department of Pharmacology–Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gea Drost
- University of Groningen, Department of Neurology and Neurosurgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Baziel G. M. van Engelen
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
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Lange S, Sauerland S, Lauterberg J, Windeler J. The Range and Scientific Value of Randomized Trials. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:635-640. [PMID: 29017690 DOI: 10.3238/arztebl.2017.0635] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 04/06/2017] [Accepted: 06/12/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The randomized, controlled trial (RCT) is the gold standard of scientific evidence for the attribution of clinical effects (benefits and harms) to medical interventions. Many different designs for RCTs have been developed in order to counter legitimate critical objections and to better adapt the trials to the continually changing challenges that face clinical research. METHODS The diversity and adaptability of randomized trial designs are presented and discussed on the basis of a selective literature review and specific illustrative examples. RESULTS A wide range of RCT designs enables adaptation to special research tasks and clinical framework conditions. These include (among others) crossover trials, n=1 trials, factorial RCT designs, and cluster-randomized trials. In addition, adaptive designs such as modern platform trials and pragmatic RCTs with simplified clinical questions and less severely restricted patient groups make broad recruitment of patients possible even in routine clinical practice. CONCLUSION Only the randomized allocation of subjects to the treatment and control groups, which is the defining property of RCTs, can adequately ensure that traits of the subjects which might disturb or bias a comparison of two or more medical interventions, will be evenly distributed across groups, regardless of whether these traits are known or unknown. The methodological variants and further elaborations of the RCT that are discussed here will help protect patients by enabling the assessment of the benefits and harms of medical methods and products on the basis of robust evidence even in the present era of rapid innovation.
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Abstract
PURPOSE OF REVIEW To review recent evidence on the efficacy and safety of methylphenidate as a symptomatic treatment of patients with cancer-related fatigue (CRF). RECENT FINDINGS Five clinical trials published since 2011 were identified. Two of these concluded that methylphenidate is more efficacious than placebo in providing relief from CRF, but the remaining three showed no difference in favour of methylphenidate. The studies were heterogeneous as per the dosage, scales used for evaluating fatigue and the target group studied. None of the studies detected serious reactions, and only mild and infrequent side-effects of methylphenidate were reported. Three new metanalyses show the slightly superior effect of methylphenidate compared to placebo in CRF. SUMMARY Overall, literature supports the existence of moderate benefit of methylphenidate in CRF, backed up by weak evidence. Future studies should aim at better identifying the profile of patients who would benefit most from this pharmacological intervention.
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Abstract
Cancer-related fatigue (CRF) significantly interferes with usual functioning because of the distressing sense of physical, emotional, and cognitive exhaustion. Assessment of CRF is important and should be performed during the initial cancer diagnosis, throughout cancer treatment, and after treatment using a fatigue scoring scale (mild-severe). The general approach to CRF management applies to cancer survivors at all fatigue levels and includes education, counseling, and other strategies. Nonpharmacologic interventions include psychosocial interventions, exercise, yoga, physically based therapy, dietary management, and sleep therapy. Pharmacologic interventions include psychostimulants. Antidepressants may also benefit when CRF is accompanied by depression.
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Affiliation(s)
- Chidinma C Ebede
- Department of General Internal Medicine, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1465, Houston, TX 77030-4008, USA
| | - Yongchang Jang
- Department of General Internal Medicine, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1465, Houston, TX 77030-4008, USA
| | - Carmen P Escalante
- Department of General Internal Medicine, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1465, Houston, TX 77030-4008, USA.
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Weinreich SS, Vrinten C, Kuijpers MR, Lipka AF, Schimmel KJM, van Zwet EW, Gispen-de Wied C, Hekster YA, Verschuuren JJGM, Cornel MC. Aggregated N-of-1 trials for unlicensed medicines for small populations: an assessment of a trial with ephedrine for myasthenia gravis. Orphanet J Rare Dis 2017; 12:88. [PMID: 28494776 PMCID: PMC5427624 DOI: 10.1186/s13023-017-0636-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/17/2017] [Indexed: 11/15/2022] Open
Abstract
Background Inexpensive medicines with a long history of use may currently be prescribed off-label for rare indications. Reimbursement is at the discretion of health insurance companies, and may be unpredictable. The example addressed was ephedrine as add-on treatment for myasthenia gravis. Stakeholders from academia, a patient organization, the Dutch National Health Care Institute (NHCI) and Dutch Medicines Evaluation Board (MEB) advised on the trial design. The NHCI and MEB agreed to provide scientific advice on the suitability of the evidence generated by the trial, for regulatory decisions. This paper describes the feasibility of the trial and the utility of its aggregated results. Results The trialists experienced the trial as feasible. Retrospective interviews showed that the trial as performed was acceptable to patients. The treatment effect in the primary outcome measure, muscle strength, was statistically significant when inferred to the population level, though the effect size was modest. Secondary outcomes were statistically significant in a preplanned, fixed effects analysis within the four patients. The NHCI advised that it could potentially make reimbursement decisions based on the Fitting Evidence framework, should the trialists decide to apply for reimbursement. The MEB advised that for a licensing decision, the N-of-1 design is a last-resort option for demonstrating treatment benefit in a rare disease. N-of-1 trials alone do not provide enough evidence on potential risk. The MEB found the current trial inconclusive. It suggested doing a 2-armed trial of longer duration, possibly with a different outcome measure (postponement of corticosteroid use). It suggested engaging a consultancy or commercial sponsor, should the trialists decide to seek market authorization of the drug. Conclusions In theory, evidence from aggregated N-of-1 trials is suitable for use in licensing and reimbursement decisions. The current example illustrates differences in interpretation of N-of-1 results by health authorities. In the era of personalized medicine, consensus is required on the interpretation of data from study designs geared to small groups. Demonstrating effectiveness of inexpensive medicines in small populations may require involvement of non-commercial parties, to preserve affordability. Electronic supplementary material The online version of this article (doi:10.1186/s13023-017-0636-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephanie S Weinreich
- Department of Clinical Genetics, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands. .,Department of Care, National Health Care Institute, Diemen, The Netherlands.
| | - Charlotte Vrinten
- Department of Clinical Genetics, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.,Department of Epidemiology and Public Health, University College London, London, UK
| | - Marja R Kuijpers
- Department of Care, National Health Care Institute, Diemen, The Netherlands
| | - Alexander F Lipka
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kirsten J M Schimmel
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Martina C Cornel
- Department of Clinical Genetics, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
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Currow DC, Abernethy AP, Fallon M, Portenoy RK. Repurposing Medications for Hospice/Palliative Care Symptom Control Is No Longer Sufficient: A Manifesto for Change. J Pain Symptom Manage 2017; 53:533-539. [PMID: 28042066 DOI: 10.1016/j.jpainsymman.2016.10.358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/11/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022]
Abstract
The World Health Organization essential medications list for hospice/palliative care reflects that, with the judicious use of currently available medications, the majority of symptoms can be lessened, and some controlled completely. Even with optimal use of current medications, symptom control is still unacceptable for many people. Currently available medications offer great benefit to a minority of patients, some benefit to an additional group, and no benefit or harms to others. In symptom control, development of new drugs is advancing at a glacial pace, contrasting to the rapid advances seen in many other disciplines. Specialists in palliative care should agree on several principles consequently: 1) Access to symptom-control drugs codified in the World Health Organization Essential Medicines list deserves the strongest support from national policies and professional guidelines, especially in resource-challenged countries. 2) The optimal use of currently available symptom-control drugs cannot yield acceptably high rates of net benefits. 3) There is a compelling need to identify patient subgroups that are likely to benefit from available medications and provide rigorous empirical support for indications, dosing, and route of administration for clinical practice. 4) New therapies are needed requiring an accelerated effort to investigate further the pathophysiology, neurobiology, and pharmacogenetics of distressing symptoms, and factors contributing to variations in drug response. This development requires a lengthy lead time. 5) Smarter ways to promote new knowledge into practice are needed as no drug will be suitable for all patients. We need to improve clinical characterization and biomarker technology to bring the best drugs to the right patients every time.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia.
| | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia; Division of Medical Oncology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Marie Fallon
- St Columba's Hospice Chair of Palliative Medicine, Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, Scotland, UK
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
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Xie T, Yu Z. N-of-1 Design and Its Applications to Personalized Treatment Studies. STATISTICS IN BIOSCIENCES 2016; 9:662-675. [PMID: 29225716 PMCID: PMC5711967 DOI: 10.1007/s12561-016-9165-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 09/17/2015] [Accepted: 08/11/2016] [Indexed: 11/30/2022]
Abstract
N-of-1 trial is a type of clinical trial which has been applied in chronic recurrent conditions that require long-term non-curative treatment. In this type of trials, each patient will be randomly assigned to one of the treatment sequences and repeatedly crossed over two or more treatments of interests. Through this cross-comparing method (cross-over phase), investigator can identify an optimal treatment (medicine or therapy) for the patient and treat the patient with the optimal treatment in an extension phase. This design could efficiently reduce the placebo effect, which is often seen in clinical trials, and maximize the true treatment effect. This type of design has been used in some traditional Chinese medicine (TCM) clinical trials lately. However, it brings some challenges for collecting and analyzing the data. Research on statistical methodology of this type of design is rarely found in the literature. The goal of this research is to discuss the application of the N-of-1 design to personalized treatment studies. We will demonstrate a real study conducted in TCM and present some theoretical and simulation results.
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Affiliation(s)
- Tailiang Xie
- Brightech International, 285 Davidson Avenue, Suite 504, Somerset, NJ 08873 USA
| | - Zhuoxin Yu
- Brightech International, 285 Davidson Avenue, Suite 504, Somerset, NJ 08873 USA
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Abstract
Symptom control at the end of life is an identified ongoing gap in end-of-life care. Increased demand for high-quality symptom control; limited supply of specialty trained clinicians; lack of consistent high-quality evidence-based interventions; and education deficits among clinicians, patients, and families in end-of-life processes contribute to this gap. High-value end-of-life care is centered on high-quality communication about goals of care. This article reviews primary palliative care concepts of communication and symptom control to provide a framework for primary care physicians to use in the care of patients at the end of life.
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Affiliation(s)
- Margaret Kreher
- Department of Medicine, Center of Excellence in Palliative Medicine, Palliative Care, Penn State MS Hershey Medical Center, Mail Code H106, PO Box 850, 500 University Drive, Hershey, PA 17033-0850, USA.
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Effects of the polysaccharides extracted from Ganoderma lucidum on chemotherapy-related fatigue in mice. Int J Biol Macromol 2016; 91:905-10. [PMID: 27208798 DOI: 10.1016/j.ijbiomac.2016.04.084] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/19/2016] [Accepted: 04/29/2016] [Indexed: 11/23/2022]
Abstract
The weight-loaded swimming capability, tumor growth, survival time and biochemical markers of Ganoderma lucidum polysaccharides (GLPs) in a chemotherapy-related fatigue mouse model were tested in the present study. The results showed that the middle-dose GLPs (GLP-M) and the high-dose GLPs (GLP-H) could increase the exhausting swimming time, which was observed to decrease in the cisplatin control group(PCG) and the tumor control group (TCG).The GLP-M and the GLP-H had reduced serum levels of tumor necrosis factor-αand interleukin-6, which were up-regulated by cisplatin. Cisplatin and the presence of tumor significantly enhanced the malondialdehyde (MDA) content and inhibited the activity of superoxide dismutase (SOD) in the muscle. Administration of GLPs at a high dose decreased the levels of MDA and up-regulated the SOD activity. The high-dose GLPs+cisplatin group presented a decreased tendency of tumor volume and a lower tumor weight compared with PCG. Moreover, the mice in the GLP-M and GLP-H groups had longer survival times compared with the mice in the TCG and PCG.The levels of creatinine and serum blood urea nitrogen, which are up-regulated by cisplatin, were significantly reduced by GLP-M and GLP-H. Therefore, these results suggest that GLPs might improve chemotherapy-related fatigue via regulation of inflammatory responses, oxidative stress and reduction of nephrotoxicity.
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Roila F, Fumi G, Fatigoni S. Management of fatigue following breast cancer treatment. BREAST CANCER MANAGEMENT 2016. [DOI: 10.2217/bmt-2016-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cancer-related fatigue (CRF) is a very distressing symptom experienced by most cancer patients. CRF is a complex symptom and there is no agreement regarding the exact definition, the best measurement instrument or even the optimal treatment. CRF is an important problem especially in breast cancer patients, during and after treatment, in long-term survivors. In the last few decades survival rates have dramatically improved. Thus, the number of breast cancer survivors has increased and preservation of quality of life has become very important. This paper is a literature review of the studies published in the last 5 years on management of CRF and breast cancer patients. We distinguished CRF during and after oncological therapy and examined both pharmacological and nonpharmacological interventions.
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Affiliation(s)
- Fausto Roila
- Medical Oncology, S. Maria Hospital, via Tristano di Joannuccio 1, Terni, Italy
| | - Guglielmo Fumi
- Medical Oncology, S. Maria Hospital, via Tristano di Joannuccio 1, Terni, Italy
| | - Sonia Fatigoni
- Medical Oncology, S. Maria Hospital, via Tristano di Joannuccio 1, Terni, Italy
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Zhai J, Cao H, Ren M, Mu W, Lv S, Si J, Wang H, Chen J, Shang H. Reporting of core items in hierarchical Bayesian analysis for aggregating N-of-1 trials to estimate population treatment effects is suboptimal. J Clin Epidemiol 2016; 76:99-107. [PMID: 26946040 DOI: 10.1016/j.jclinepi.2016.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES N-of-1 trials can be aggregated to estimate population treatment effects using hierarchical Bayesian models. It is very important to report core items in hierarchical Bayesian analysis. In this study, we assessed reporting of items in hierarchical Bayesian analysis for aggregating N-of-1 trials to estimate population treatment effects. STUDY DESIGN AND SETTING This was a systematic literature review of aggregating N-of-1 trials by hierarchical Bayesian models to estimate population treatment effects. A comprehensive search was performed to collect eligible articles. Pilot studies, formal N-of-1 trials and reports in which the data were reanalyzed using hierarchical Bayesian methods, were included. The information of reported items related with hierarchical Bayesian analysis was extracted by two independent reviewers. The guideline "ROBUST," developed for reporting Bayesian analysis of clinical studies, was published in Journal of Clinical Epidemiology in 2005. We assessed the included reports using ROBUST criteria and 18 other important items. RESULTS After careful screening, 11 studies were identified to be eligible for inclusion. There were three pilot studies, four formal trials, and four reports in which the data were reanalyzed using hierarchical Bayesian methods. The number of reported items in ROBUST criteria ranged from six to seven, with a median number of six. Five of eleven included articles reported all items of the ROBUST criteria. But for justification and sensitivity analysis in prior distribution items, other items were reported in all of the included articles. Software and analysis data set items were reported the most frequently in additional items excluded from the ROBUST criteria. Less than half of the studies reported the other additional items. CONCLUSION Reporting of core items in hierarchical Bayesian analysis for aggregating N-of-1 trials to estimate population treatment effects is suboptimal. A PRISMA-like guidance on reviews of Bayesian N-of-1 trials may be required in the future.
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Affiliation(s)
- Jingbo Zhai
- Research Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Hongbo Cao
- Research Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Ming Ren
- Baokang Hospital, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Wei Mu
- Second Affiliated Hospital, Tianjin University of Traditional Chinese Medicine, 816 Zhenli Street, Hebei District, Tianjin 300150, China
| | - Sisi Lv
- Modern Educational Technology and Information Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jinhua Si
- Library of Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Hui Wang
- Research Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Jing Chen
- Baokang Hospital, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China.
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China.
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Bruera E. The Role of Methylphenidate in Cancer-Related Fatigue. Commentary on Mitchell et al. J Pain Symptom Manage 2015; 50:287. [PMID: 26254017 DOI: 10.1016/j.jpainsymman.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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