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Romantsik O, Bank M, Menon JML, Malhotra A, Bruschettini M. Value of preclinical systematic reviews and meta-analyses in pediatric research. Pediatr Res 2024:10.1038/s41390-024-03197-1. [PMID: 38615075 DOI: 10.1038/s41390-024-03197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/15/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024]
Abstract
Similar to systematic reviews (SRs) in clinical fields, preclinical SRs address a specific research area, furnishing information on current knowledge, possible gaps, and potential methodological flaws of study design, conduct, and report. One of the main goals of preclinical SRs is to identify aspiring treatment strategies and evaluate if currently available data is solid enough to translate to clinical trials or highlight the gaps, thus justifying the need for new studies. It is imperative to rigorously follow the methodological standards that are widely available. These include registration of the protocol and adherence to guidelines for assessing the risk of bias, study quality, and certainty of evidence. A special consideration should be made for pediatric SRs, clinical and preclinical, due to the unique characteristics of this age group. These include rationale for intervention and comparison of primary and secondary outcomes. Outcomes measured should acknowledge age-related physiological changes and maturational processes of different organ systems. It is crucial to choose the age of the animals appropriately and its possible correspondence for specific pediatric age groups. The findings of well-conducted SRs of preclinical studies have the potential to provide a reliable evidence synthesis to guide the design of future preclinical and clinical studies. IMPACT: This narrative review highlights the importance of rigorous design, conduct and reporting of preclinical primary studies and systematic reviews. A special consideration should be made for pediatric systematic reviews of preclinical studies, due to the unique characteristics of this age group.
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Affiliation(s)
- Olga Romantsik
- Department of Clinical Sciences Lund, Division of Pediatrics, Lund University, Skåne University Hospital, Lund, 21185, Sweden.
| | - Matthias Bank
- Library and ICT, Faculty of Medicine, Lund University, Lund, Sweden
| | - Julia M L Menon
- Preclinicaltrials.eu, Netherlands Heart Institute, Utrecht, The Netherlands
| | - Atul Malhotra
- Department of Pediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Division of Pediatrics, Lund University, Skåne University Hospital, Lund, 21185, Sweden
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2
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Modanloo S, Correll Q, Correll R, Major N, Quinlan M, Reszel J, Wilding J, Lin Zhou Z, Franck LS, Harrison D. Identifying research priorities with children, youth, and families: A scoping review. J Child Health Care 2023:13674935231151748. [PMID: 36647285 DOI: 10.1177/13674935231151748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Increased patient advocacy has resulted in a shift toward more active patient engagement in the research. A scoping review was conducted to explore the literature on healthcare research priority settings wherein children, youths, or their families were involved in the priority-setting process. Six databases including MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Global Health and the James Lind Alliance website were searched up until September 2019. All primary studies involving children (<18 years of age) or families in developing research priorities in health care were included. All retrieved references were uploaded into Covidence, and two independent reviewers screened the search results. Descriptive thematic analysis was used to identify common themes. A total of 30 studies with 4247 participants were included. Less than half of the participants (n = 1237, (33%) were pediatric patients and their families. A total of 455 research priorities were identified. Three common themes emerged: (i) quality of care delivery, (ii) self-efficacy in health behaviors, and (iii) community engagement in care. This scoping review revealed priority research health topics from the perspectives of children, youths, or their families. The findings may be used as a foundation for future research to improve the health outcomes of children, youths, or their families according to their identified priorities.
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Affiliation(s)
- Shokoufeh Modanloo
- Arthur Labatt School of Nursing, Faculty of Health Sciences, 70383Western University, London, ON, Canada
| | - Quinn Correll
- Rankin School of Nursing, St Francis Xavier University, Antigonish, NS, Canada
| | - Rhonda Correll
- Children's Hospital of Eastern Ontario 274065(CHEO) Research Institute, Ottawa, ON, Canada
| | - Nathalie Major
- Children's Hospital of Eastern Ontario 274065(CHEO) Research Institute, Ottawa, ON, Canada
| | - Michelle Quinlan
- Children's Hospital of Eastern Ontario 274065(CHEO) Research Institute, Ottawa, ON, Canada
| | - Jessica Reszel
- Children's Hospital of Eastern Ontario 274065(CHEO) Research Institute, Ottawa, ON, Canada
| | - Jodi Wilding
- Children's Hospital of Eastern Ontario 274065(CHEO) Research Institute, Ottawa, ON, Canada
| | - Zhi Lin Zhou
- Children's Hospital of Eastern Ontario 274065(CHEO) Research Institute, Ottawa, ON, Canada
| | - Linda S Franck
- School of Nursing, 8783University of California, San Francisco, CA, USA
| | - Denise Harrison
- Department of Nursing, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
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3
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Mogensen AKB, Christiansen H, De Bruin ML, Hallgreen CE. New Information on Old Medicinal Products: A Cross-Sectional Analysis of Guidance for Paediatric Use for Substances on the European Priority List of Off-Patent Medicinal Products. Paediatr Drugs 2022; 24:679-687. [PMID: 35962257 DOI: 10.1007/s40272-022-00530-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND As part of the European Paediatric Regulation, the European Medicines Agency (former European Medicines Evaluation Agency) and the Paediatric Working Party (precursor for the Paediatric Committee) revised a priority list for studies on off-patent medicinal products in 2007 where a need for studies on paediatric medicinal products was emphasised. OBJECTIVES We aimed to evaluate the status of guidance for paediatric use in the Summary of Product Characteristics for medicinal products on the priority list as well as the presence and status of Paediatric Investigation Plans for these medicinal products. METHODS We included active pharmaceutical ingredients on the priority list authorised through the centralised procedure and/or marketed in Denmark. The status of guidance for paediatric use (indication, posology and/or contraindication) was reviewed from the most recent Summary of Product Characteristics uploaded on the European Medicines Agency or the Danish Medicines Agency website as of November 2020. Information on Paediatric Investigation Plans status (Paediatric Committee opinion, completion and waivers granted) was retrieved from the European Medicines Agency website. RESULTS A total of 121 active pharmaceutical ingredients were included in this study. Seventy-one percent had guidance for paediatric use in the Summary of Product Characteristics for at least one paediatric subpopulation, more often concerning adolescents (70%) and children (70%) as compared with neonates (41%) and infants (49%). The guidance included a paediatric indication in 46% of the cases, but less often a contraindication (13%). Thirty-three active pharmaceutical ingredients had an agreed Paediatric Investigation Plan, six of these were completed. CONCLUSIONS Most active pharmaceutical ingredients from the priority list had guidance for paediatric use in the Summary of Product Characteristics. However, there is still an unmet need in relation to guidance for use for the youngest paediatric subpopulation.
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Affiliation(s)
- Ann-Katrine Birkelund Mogensen
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Helle Christiansen
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie Louise De Bruin
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Christine Erikstrup Hallgreen
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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4
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Gill PJ, Bayliss A, Sozer A, Buchanan F, Breen-Reid K, De Castris-Garcia K, Green M, Quinlan M, Wong N, Frappier S, Cowan K, Chan C, Arafeh D, Anwar MR, Macarthur C, Parkin PC, Cohen E, Mahant S. Patient, Caregiver, and Clinician Participation in Prioritization of Research Questions in Pediatric Hospital Medicine. JAMA Netw Open 2022; 5:e229085. [PMID: 35471568 PMCID: PMC9044112 DOI: 10.1001/jamanetworkopen.2022.9085] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE The research agenda in pediatric hospital medicine has seldom considered the perspectives of young people, parents and caregivers, and health care professionals. Their perspectives may be useful in identifying questions on topics for research. OBJECTIVE To prioritize unanswered research questions in pediatric hospital medicine from the perspectives of young people, parents/caregivers, and health care professionals. DESIGN, SETTING, AND PARTICIPANTS Between August 4, 2020, and August 19, 2021, two online surveys and a virtual workshop were conducted, using modified Delphi technique and nominal group technique. Young people, parents/caregivers, and health care professionals with experiences in pediatric hospital medicine in Canada were included. INTERVENTIONS The established James Lind Alliance Priority Setting Partnership method was used. In phase 1, a survey collected unanswered questions regarding pediatric hospital medicine via 3 open-ended questions. Survey responses were used to develop summary questions that went through an evidence-checking process. Unanswered questions were brought to a phase 2 interim prioritization survey. The top 10 unanswered research questions in pediatric hospital medicine were established at the final priority setting workshop. MAIN OUTCOMES AND MEASURES Survey responses, top 10 research questions. RESULTS The phase 1 survey was completed by 188 participants (148 of 167 [89%] females; 17 of 167 [10%] males; mean [SD] age, 39.5 [12.4] years) and generated 495 unanswered research questions and comments, of which 58 were deemed out of scope. The remaining 437 responses were grouped into themes (eg, communication, shared decision-making, health service delivery, and health service management) and then refined to 75 unanswered research questions. Of these 75, only 4 questions had sufficient evidence. To make the number of questions in phase 2 manageable, 21 questions submitted by only 1 respondent were eliminated. Fifty unanswered research questions were included in the phase 2 survey, which was completed by 201 participants (165 of 186 [89%] females; 19 of 186 [10%] males; mean [SD] age, 40.0 [11.0] years). A short list of 16 questions-the top 10 questions from patient partners (youths, parents/caregivers) and clinicians-was presented at the final priority setting workshop and the top 10 questions were prioritized. The top 10 questions focused on the care of special inpatient populations (eg, children with medical complexity), communication, shared decision-making, support strategies in the hospital, mental health supports, shortening length of stay, and supporting Indigenous patients, parents/caregivers, and families. CONCLUSIONS AND RELEVANCE This patient-oriented pediatric hospital medicine priority setting partnership identified the most important unanswered research questions focused on the care of children in the hospital. These questions provide a possible roadmap for research on areas deemed important to young people, parents/caregivers, and clinicians.
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Affiliation(s)
- Peter J. Gill
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Pediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Aubrey Sozer
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Francine Buchanan
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Research Family Advisory Committee, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Mairead Green
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Michelle Quinlan
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Noel Wong
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Learning Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shelley Frappier
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | | | - Carol Chan
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Dana Arafeh
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Rashid Anwar
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Colin Macarthur
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Tukayo BLA, Sunderland B, Parsons R, Czarniak P. High prevalence of off-label and unlicensed paediatric prescribing in a hospital in Indonesia during the period Aug.-Oct. 2014. PLoS One 2020; 15:e0227687. [PMID: 31935254 PMCID: PMC6959587 DOI: 10.1371/journal.pone.0227687] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/22/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on off-label and unlicensed prescribing in children in Indonesia is limited. The aims of this study were to determine the prevalence of off-label and unlicensed prescribing for paediatric patients in a public hospital, Indonesia. METHOD A retrospective cross-sectional study of 200 randomly selected paediatric patients admitted to hospital between August and October 2014, collected patient details and all drugs prescribed. Licensed drugs were classified as off-label if there was a non-compliance with the Product Information for age, weight, indication, dose, frequency and route of administration, if there was a contraindication, special precautions or not recommended for children. Unlicensed drugs were those not approved for use in Indonesia. The main outcome was the prevalence of off-label or unlicensed prescribing to infants, children and adolescents and the impact of age group on off-label prescribing. RESULTS A total of 200 patients received 1961 medicines of which 1807/1961 (92.1%) were licensed and 154/1961 (7.9%) were unlicensed. There were 1403/1961 (71.5%) drugs prescribed off-label. More than half of the total drugs (n = 1066; 54.4%) were administered parenterally. Every patient was prescribed at least one off-label drug. Indication (n = 810; 34.6%) was the most common reason for off-label prescribing. Ranitidine was the most frequent drug prescribed off label. Darplex® (dihydroartemisinin and piperaquine), although manufactured in Indonesia, was unlicensed. There was a significant difference between age group and off-label prescribing in that children were prescribed significantly less off-label drugs (p<0.0003). CONCLUSION This study revealed a high prevalence of off-label and unlicensed drug use in paediatric patients in this hospital, exposing them to drug treatments or regimens that had not been approved by regulatory authorities. The high incidence of invasive parenteral prescribing is of concern for paediatric patients. Incentives are needed to encourage specific drug evaluation in paediatric populations.
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Affiliation(s)
- Brechkerts Lieske Angruni Tukayo
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
- Health Polytechnic Jayapura Indonesian Ministry of Health, Jakarta, Indonesia
| | - Bruce Sunderland
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Richard Parsons
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
| | - Petra Czarniak
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
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6
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Liu P, Ioannidis JPA, Ross JS, Dhruva SS, Luxkaranayagam AT, Vasiliou V, Wallach JD. Age-treatment subgroup analyses in Cochrane intervention reviews: a meta-epidemiological study. BMC Med 2019; 17:188. [PMID: 31639007 PMCID: PMC6805640 DOI: 10.1186/s12916-019-1420-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/04/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is growing interest in evaluating differences in healthcare interventions across routinely collected demographic characteristics. However, individual subgroup analyses in randomized controlled trials are often not prespecified, adjusted for multiple testing, or conducted using the appropriate statistical test for interaction, and therefore frequently lack credibility. Meta-analyses can be used to examine the validity of potential subgroup differences by collating evidence across trials. Here, we characterize the conduct and clinical translation of age-treatment subgroup analyses in Cochrane reviews. METHODS For a random sample of 928 Cochrane intervention reviews of randomized trials, we determined how often subgroup analyses of age are reported, how often these analyses have a P < 0.05 from formal interaction testing, how frequently subgroup differences first observed in an individual trial are later corroborated by other trials in the same meta-analysis, and how often statistically significant results are included in commonly used clinical management resources (BMJ Best Practice, UpToDate, Cochrane Clinical Answers, Google Scholar, and Google search). RESULTS Among 928 Cochrane intervention reviews, 189 (20.4%) included plans to conduct age-treatment subgroup analyses. The vast majority (162 of 189, 85.7%) of the planned analyses were not conducted, commonly because of insufficient trial data. There were 22 reviews that conducted their planned age-treatment subgroup analyses, and another 3 reviews appeared to perform unplanned age-treatment subgroup analyses. These 25 (25 of 928, 2.7%) reviews conducted a total of 97 age-treatment subgroup analyses, of which 65 analyses (in 20 reviews) had non-overlapping subgroup levels. Among the 65 age-treatment subgroup analyses, 14 (21.5%) did not report any formal interaction testing. Seven (10.8%) reported P < 0.05 from formal age-treatment interaction testing; however, none of these seven analyses were in reviews that discussed the potential biological rationale or clinical significance of the subgroup findings or had results that were included in common clinical practice resources. CONCLUSION Age-treatment subgroup analyses in Cochrane intervention reviews were frequently planned but rarely conducted, and implications of detected interactions were not discussed in the reviews or mentioned in common clinical resources. When subgroup analyses are performed, authors should report the findings, compare the results to previous studies, and outline any potential impact on clinical care.
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Affiliation(s)
- Patrick Liu
- Yale School of Medicine, New Haven, CT, 06510, USA
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford School of Medicine, Stanford, CA, 94305, USA.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, 94305, USA.,Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA.,Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, CA, 94305, USA
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Health System, New Haven, CT, 06510, USA.,Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA.,National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, 06510, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Sanket S Dhruva
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, USA.,Section of Cardiology, San Francisco Veterans Affairs Health Care System, San Francisco, CA, 94121, USA
| | | | - Vasilis Vasiliou
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Joshua D Wallach
- Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Health System, New Haven, CT, 06510, USA. .,Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, 06510, USA. .,Collaboration for Research Integrity and Transparency (CRIT), Yale Law School, New Haven, CT, 06510, USA.
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7
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Odgers HL, Tong A, Lopez-Vargas P, Davidson A, Jaffe A, McKenzie A, Pinkerton R, Wake M, Richmond P, Crowe S, Caldwell PHY, Hill S, Couper J, Haddad S, Kassai B, Craig JC. Research priority setting in childhood chronic disease: a systematic review. Arch Dis Child 2018; 103:942-951. [PMID: 29643102 DOI: 10.1136/archdischild-2017-314631] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate research priority setting approaches in childhood chronic diseases and to describe the priorities of stakeholders including patients, caregivers/families and health professionals. DESIGN We conducted a systematic review of MEDLINE, Embase, PsycINFO and CINAHL from inception to 16 October 2016. Studies that elicited stakeholder priorities for paediatric chronic disease research were eligible for inclusion. Data on the prioritisation process were extracted using an appraisal checklist. Generated priorities were collated into common topic areas. RESULTS We identified 83 studies (n=15 722). Twenty (24%) studies involved parents/caregivers and four (5%) children. The top three health areas were cancer (11%), neurology (8%) and endocrine/metabolism (8%). Priority topic areas were treatment (78%), disease trajectory (48%), quality of life/psychosocial impact (48%), disease onset/prevention (43%), knowledge/self-management (33%), prevalence (30%), diagnostic methods (28%), access to healthcare (25%) and transition to adulthood (12%). The methods included workshops, Delphi techniques, surveys and focus groups/interviews. Specific methods for collecting and prioritising research topics were described in only 60% of studies. Most reviewed studies were conducted in high-income nations. CONCLUSIONS Research priority setting activities in paediatric chronic disease cover many discipline areas and have elicited a broad range of topics. However, child/caregiver involvement is uncommon, and the methods often lack clarity. A systematic and explicit process that involves patients and families in partnership may help to inform a more patient and family-relevant research agenda in paediatric chronic disease.
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Affiliation(s)
- Harrison Lindsay Odgers
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Pamela Lopez-Vargas
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Kid's Research Institute, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Andrew Davidson
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, France.,Department of Anaesthesiology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Adam Jaffe
- Department of Respiratory Medicine, The Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Paediatrics, The University of New South Wales, Sydney, New South Wales, Australia
| | - Anne McKenzie
- Western Australian Health Translation Network, The University of Western Australia, Perth, Western Australia, Australia
| | - Ross Pinkerton
- Department of Oncology, Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia
| | - Melissa Wake
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, France.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, The Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Peter Richmond
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Departments of General Paediatrics and Immunology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | | | - Patrina Ha Yuen Caldwell
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Nephrology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Sophie Hill
- Center for Health Communication and Participation, La Trobe University, Melbourne, Victoria, Australia
| | - Jennifer Couper
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Suzy Haddad
- Patient and Carer Representative, Sydney, New South Wales, Australia
| | - Behrouz Kassai
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Centre d'Investigation Clinique de Lyon, Lyon, France
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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8
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Vandermeer B, van der Tweel I, Jansen-van der Weide MC, Weinreich SS, Contopoulos-Ioannidis DG, Bassler D, Fernandes RM, Askie L, Saloojee H, Baiardi P, Ellenberg SS, van der Lee JH. Comparison of nuisance parameters in pediatric versus adult randomized trials: a meta-epidemiologic empirical evaluation. BMC Med Res Methodol 2018; 18:7. [PMID: 29321002 PMCID: PMC5763521 DOI: 10.1186/s12874-017-0456-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 12/11/2017] [Indexed: 01/19/2023] Open
Abstract
Background We wished to compare the nuisance parameters of pediatric vs. adult randomized-trials (RCTs) and determine if the latter can be used in sample size computations of the former. Methods In this meta-epidemiologic empirical evaluation we examined meta-analyses from the Cochrane Database of Systematic-Reviews, with at least one pediatric-RCT and at least one adult-RCT. Within each meta-analysis of binary efficacy-outcomes, we calculated the pooled-control-group event-rate (CER) across separately all pediatric and adult-trials, using random-effect models and subsequently calculated the control-group event-rate risk-ratio (CER-RR) of the pooled-pediatric-CERs vs. adult-CERs. Within each meta-analysis with continuous outcomes we calculated the pooled-control-group effect standard deviation (CE-SD) across separately all pediatric and adult-trials and subsequently calculated the CE-SD-ratio of the pooled-pediatric-CE-SDs vs. adult-CE-SDs. We then calculated across all meta-analyses the pooled-CER-RRs and pooled-CE-SD-ratios (primary endpoints) and the pooled-magnitude of effect-sizes of CER-RRs and CE-SD-ratios using REMs. A ratio < 1 indicates that pediatric trials have smaller nuisance parameters than adult trials. Results We analyzed 208 meta-analyses (135 for binary-outcomes, 73 for continuous-outcomes). For binary outcomes, pediatric-RCTs had on average 10% smaller CERs than adult-RCTs (summary-CE-RR: 0.90; 95% CI: 0.83, 0.98). For mortality outcomes the summary-CE-RR was 0.48 (95% CIs: 0.31, 0.74). For continuous outcomes, pediatric-RCTs had on average 26% smaller CE-SDs than adult-RCTs (summary-CE-SD-ratio: 0.74). Conclusions Clinically relevant differences in nuisance parameters between pediatric and adult trials were detected. These differences have implications for design of future studies. Extrapolation of nuisance parameters for sample-sizes calculations from adult-trials to pediatric-trials should be cautiously done.
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Affiliation(s)
- Ben Vandermeer
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Ingeborg van der Tweel
- Department of Biostatistics, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, Netherlands
| | | | - Stephanie S Weinreich
- Pediatric Clinical Research Office, Emma Children's Hospital, Academic Medical Centre, Amsterdam, Netherlands.,Department of Clinical Genetics, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Despina G Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, CA, USA.,Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Dirk Bassler
- Department of Neonatology, University Hospital, Zurich and University of Zurich, Zurich, Switzerland
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.,Department of Pediatrics, Santa Maria Hospital, Lisbon, Portugal
| | - Lisa Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Haroon Saloojee
- Division of Community Pediatrics, Department of Pediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Susan S Ellenberg
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Johanna H van der Lee
- Pediatric Clinical Research Office, Emma Children's Hospital, Academic Medical Centre, Amsterdam, Netherlands.
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9
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Tedesco D, Farid-Kapadia M, Offringa M, Bhutta ZA, Maldonado Y, Ioannidis JPA, Contopoulos-Ioannidis DG. Comparative evidence on harms in pediatric randomized clinical trials from less developed versus more developed countries is limited. J Clin Epidemiol 2017; 95:63-72. [PMID: 29191447 DOI: 10.1016/j.jclinepi.2017.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 11/15/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Evaluate comparative harm rates from medical interventions in pediatric randomized clinical trials (RCTs) from more developed (MDCs) and less developed countries (LDCs). STUDY DESIGN AND SETTING Meta-epidemiologic empirical evaluation of Cochrane Database of Systematic Reviews (June 2014) meta-analyses reporting clinically important harm-outcomes (severe adverse events [AEs], discontinuations due to AEs, any AE, and mortality) that included at least one pediatric RCT from MDCs and at least one from LDCs. We estimated relative odds ratios (RORs) for each harm, within each meta-analysis, between RCTs from MDCs and LDCs and calculated random-effects-summary-RORs (sRORs) for each harm across multiple meta-analyses. RESULTS Only 1% (26/2,363) of meta-analyses with clinically important harm-outcomes in the entire Cochrane Database of Systematic Reviews included pediatric RCTs both from MDCs and LDCs. We analyzed 26 meta-analyses with 244 data sets from pediatric RCTs, 116 from MDCs and 128 from LDCs (64 and 66 unique RCTs respectively). The summary ROR was 0.92 (95% confidence intervals: 0.78-1.08) for severe AEs; 1.13 (0.54-2.34) for discontinuations due to AEs; 1.10 (0.77-1.59) for any AE; and 0.99 (0.61-1.61) for mortality and for the all-harms-combined-end point 0.96 (0.83-1.10). Differences of ROR-point-estimates ≥2-fold between MDCs and LDCs were identified in 35% of meta-analyses. CONCLUSION We found no major systematic differences in harm rates in pediatric trials between MDCs and LDCs, but data on harms in children were overall very limited.
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Affiliation(s)
- Dario Tedesco
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Mufiza Farid-Kapadia
- Department of Pediatrics, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children University of Toronto, 555 University Avenue, Toronto, Ontario M5G-1X8, Canada
| | - Martin Offringa
- Department of Pediatrics, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children University of Toronto, 555 University Avenue, Toronto, Ontario M5G-1X8, Canada
| | - Zulfiqar A Bhutta
- Department of Pediatrics, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children University of Toronto, 555 University Avenue, Toronto, Ontario M5G-1X8, Canada; Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Suite 11.9805, Toronto, ON, M5G-0A4, Canada; Center of Excellence in Women and Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Yvonne Maldonado
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, 300 Pasteur Drive, Room G312, Stanford, CA 94305, USA; Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane, HRP Redwood Building, Stanford, CA 94305, USA; Senior Associate Dean for Faculty Development and Diversity, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - John P A Ioannidis
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane, HRP Redwood Building, Stanford, CA 94305, USA; Department of Medicine, Stanford Prevention Research Center, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA 94305, USA; Meta Research Innovation Center at Stanford (METRICS), 1070 Arastradero Road, Palo Alto, CA 94304, USA
| | - Despina G Contopoulos-Ioannidis
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, 300 Pasteur Drive, Room G312, Stanford, CA 94305, USA; Meta Research Innovation Center at Stanford (METRICS), 1070 Arastradero Road, Palo Alto, CA 94304, USA.
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10
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Berthod C, Kassaï B, Boussageon R, Adelaide L, Jacquet-Lagrèze M, Lajoinie A. [Justification of off-label antibiotics uses in hospitalized children]. Therapie 2017. [PMID: 28647107 DOI: 10.1016/j.therap.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Unlicensed and off-label (UL/OL) drugs are commonly used in pediatrics wards, especially the antibiotics. It remains unclear if this strategy is justified by randomized controlled trials of good quality? OBJECTIVE The aim of this study was to compare the level of evidence of UL/OL antibiotics prescription in hospitalized children. The initial hypothesis was that the UL/OL antibiotics prescriptions had a lower level of evidence than licensed antibiotics. METHOD This observational study assessed the antibiotics prescription in the children mother and women hospital of Lyon. Each antibiotic medicine courses was classified depending on: (i) they were licensed, UL or OL, (ii) their level of evidence for efficiency (sufficient evidence, insufficient evidence, no evidence) and (iii) the existence or not of randomized controlled trials (RCT) or not. The antibiotics medicine courses in atypical cases were excluded (rare disease, lack of diagnosis, comorbidities modifying antibiotic use). Data were collected with computerized patient file data. The data were compared using Fisher exact test and χ2. RESULTS One hundred and eight medicine courses were identified, corresponding to 72 mono, bi or tri-antibiotic therapies administered to 62 patients; 34% were OL and 66% were licensed. No prescriptions were UL. Thirty-two prescriptions were excluded from the evidence assessment. No proof of efficiency was found for any of the 76 analyzed medicine courses. RCTs were found for 36 of the analyzed medicine courses (47%); licensed medicine courses were significantly more justified by RCTs than UL/OL medicine courses (63% vs. 16%, P<0.001). DISCUSSION This study has shown the absence of RCTs of good quality to justify the prescriptions of antibiotics in pediatrics, regardless their license status. Nevertheless, the licensed prescriptions have shown more data of efficiency than OL prescriptions. Still, even when data were found, no antibiotics prescriptions reach the threshold of good quality studies. New clinical trials should respond to the patient needs.
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Affiliation(s)
- Christelle Berthod
- Centre d'investigation clinique pédiatrique CIC 1407 Inserm-UMR 5558 CNRS Lyon, université et hospices civils de Lyon, 69003 Lyon, France.
| | - Behrouz Kassaï
- Centre d'investigation clinique pédiatrique CIC 1407 Inserm-UMR 5558 CNRS Lyon, université et hospices civils de Lyon, 69003 Lyon, France; Département de pharmacologie clinique et d'essais cliniques, UMR 5558, Lyon université, 69003 Lyon, France
| | - Remy Boussageon
- Département de médecine générale, université de Poitiers UFR de médecine et pharmacie, 86000 Poitiers, France
| | - Léopold Adelaide
- Service des maladies infectieuses et tropicales, hôpital Édouard-Herriot, hospices civils de Lyon, 69003 Lyon, France
| | - Matthias Jacquet-Lagrèze
- Service d'anesthésie réanimation, centre hospitalier Louis-Pradel, hospices civils de Lyon, 69500, Bron, France
| | - Audrey Lajoinie
- Centre d'investigation clinique pédiatrique CIC 1407 Inserm-UMR 5558 CNRS Lyon, université et hospices civils de Lyon, 69003 Lyon, France; Département de pharmacologie clinique et d'essais cliniques, UMR 5558, Lyon université, 69003 Lyon, France
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11
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Farid-Kapadia M, Joachim KC, Balasingham C, Clyburne-Sherin A, Offringa M. Are child-centric aspects in newborn and child health systematic review and meta-analysis protocols and reports adequately reported?-two systematic reviews. Syst Rev 2017; 6:31. [PMID: 28260528 PMCID: PMC5338085 DOI: 10.1186/s13643-017-0423-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 01/26/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Evidence suggests that newborn and child health systematic reviews and meta-analyses exhibit poor quality in reporting. The "Preferred Reporting Items in Systematic Review and Meta-Analysis" (PRISMA) and PRISMA-Protocols (PRISMA-P) checklists have been developed to improve the reporting of systematic review results and protocols, respectively. We aimed to evaluate the clarity and transparency in reporting of child-centric items in child health systematic reviews (SRs) and SR protocols and to identify areas where reporting could be strengthened. METHODS Two preliminary lists of potential child-centric reporting items were used to examine current reporting. The Cochrane, DARE, MEDLINE, and EMBASE libraries were searched from 2010 to 2014 for systematic reviews that included children. Each report and protocol that met the inclusion criteria had their quality of reporting assessed by their reporting of child-centric items. Quality of reporting was assessed per whether one third, one to two thirds, or more than two thirds of papers complied with potential child-centric potential modifications/extensions to PRISMA and were analyzed by the following: (i) paper type (i.e., report vs. protocol), (ii) publication type (i.e., Cochrane vs. non-Cochrane), and (iii) population type (i.e., child-only vs. mixed populations vs. family/maternal). RESULTS Of the 414 eligible articles, 248 reports and 76 protocols were included. In 21 of 24 potential SR reporting items and 13 of 14 potential SR protocol reporting items, less than two thirds of papers met the child-centric reporting item requirements. Mixed population studies displayed significantly poorer reporting in comparison to child-only and family/maternal intervention studies for 11 potential SR reporting items (p < 0.05) and five potential SR protocol items (p < 0.05). When comparing non-Cochrane to Cochrane reports and protocols, five items in both lists were found to perform significantly poorer in non-Cochrane reports (p < 0.05). Significant differences in reporting quality were found in three of 14 items shared between the potential SR reporting items and potential SR protocol reporting items (p < 0.05). CONCLUSIONS Newborn and child health systematic reviews and meta-analyses exhibit incomplete reporting, thereby hindering prudent decision-making by healthcare providers and policy makers. These results provide a rationale for the implementation of child-centric extensions and modifications to current PRISMA and PRISMA-P, such as to improve reporting in this population.
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Affiliation(s)
- Mufiza Farid-Kapadia
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4 Canada
| | - Kariym C. Joachim
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4 Canada
| | - Chrinna Balasingham
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4 Canada
| | - April Clyburne-Sherin
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4 Canada
| | - Martin Offringa
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4 Canada
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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12
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Farid-Kapadia M, Askie L, Hartling L, Contopoulos-Ioannidis D, Bhutta ZA, Soll R, Moher D, Offringa M. Do systematic reviews on pediatric topics need special methodological considerations? BMC Pediatr 2017; 17:57. [PMID: 28260530 PMCID: PMC5338083 DOI: 10.1186/s12887-017-0812-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/13/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Systematic reviews are key tools to enable decision making by healthcare providers and policymakers. Despite the availability of the evidence based Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA-2009 and PRISMA-P 2015) statements that were developed to improve the transparency and quality of reporting of systematic reviews, uncertainty on how to deal with pediatric-specific methodological challenges of systematic reviews impairs decision-making in child health. In this paper, we identify methodological challenges specific to the design, conduct and reporting of pediatric systematic reviews, and propose a process to address these challenges. DISCUSSION One fundamental decision at the outset of a systematic review is whether to focus on a pediatric population only, or to include both adult and pediatric populations. Both from the policy and patient care point of view, the appropriateness of interventions and comparators administered to pre-defined pediatric age subgroup is critical. Decisions need to be based on the biological plausibility of differences in treatment effects across the developmental trajectory in children. Synthesis of evidence from different trials is often impaired by the use of outcomes and measurement instruments that differ between trials and are neither relevant nor validated in the pediatric population. Other issues specific to pediatric systematic reviews include lack of pediatric-sensitive search strategies and inconsistent choices of pediatric age subgroups in meta-analyses. In addition to these methodological issues generic to all pediatric systematic reviews, special considerations are required for reviews of health care interventions' safety and efficacy in neonatology, global health, comparative effectiveness interventions and individual participant data meta-analyses. To date, there is no standard approach available to overcome this problem. We propose to develop a consensus-based checklist of essential items which researchers should consider when they are planning (PRISMA-PC-Protocol for Children) or reporting (PRISMA-C-reporting for Children) a pediatric systematic review. Available guidelines including PRISMA do not cover the complexity associated with the conduct and reporting of systematic reviews in the pediatric population; they require additional and modified standards for reporting items. Such guidance will facilitate the translation of knowledge from the literature to bedside care and policy, thereby enhancing delivery of care and improving child health outcomes.
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Affiliation(s)
- Mufiza Farid-Kapadia
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Lisa Askie
- Systematic Reviews & Health Technology Assessment, NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Despina Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases Stanford University School of Medicine, Stanford, USA and Meta-Research Innovation Center at Stanford (METRICS), Stanford, USA
| | - Zulfiqar A. Bhutta
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Roger Soll
- University of Vermont College of Medicine and Cochrane Neonatal Review Group, Burlington, USA
| | - David Moher
- Centres for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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13
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Hüttner FJ, Diener MK. Sutures and surgical site infections: children versus adults and single centre versus multicentre trials. THE LANCET. INFECTIOUS DISEASES 2016; 17:3-4. [PMID: 27658561 DOI: 10.1016/s1473-3099(16)30317-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Felix J Hüttner
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Study Center of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Study Center of the German Surgical Society, University of Heidelberg, Heidelberg, Germany.
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14
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Dechartres A, Trinquart L, Faber T, Ravaud P. Empirical evaluation of which trial characteristics are associated with treatment effect estimates. J Clin Epidemiol 2016; 77:24-37. [DOI: 10.1016/j.jclinepi.2016.04.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/04/2015] [Accepted: 04/11/2016] [Indexed: 12/30/2022]
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15
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Contopoulos-Ioannidis D, Tseretopoulou X, Ancker M, Walterspiel JN, Panagiotou OA, Maldonado Y, Ioannidis JPA. Comparative rates of harms in randomized trials from more developed versus less developed countries may be different. J Clin Epidemiol 2016; 78:10-21. [PMID: 27063207 DOI: 10.1016/j.jclinepi.2016.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 01/04/2016] [Accepted: 02/04/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We set up to evaluate the relative risk of harms in trials performed in less developed vs. more developed countries. STUDY DESIGN AND SETTING Meta-epidemiologic evaluation using the Cochrane Database of Systematic Reviews. We considered meta-analyses with at least one randomized clinical trial (RCT) in a less developed country and one RCT in a more developed country. We targeted severe adverse events (AEs), discontinuations due to AEs, any AE, organ system-specific AEs, individual AEs, and all discontinuations due to any reason. We estimated the relative odds ratio (ROR) of harms between more and less developed countries for each topic and the summary ROR (sROR) across topics under each category of harms. RESULTS We identified 42 systematic reviews (128 meta-analyses, 521 independent RCTs). Summary sRORs did not differ significantly from 1.00 for any harm category. Nominally significant RORs were found in only 6/128 meta-analyses. However, in 27% (35/128) of meta-analyses the ROR point estimates indicated relative differences between country settings >2-fold. Considering also ROR 95% confidence intervals, in 92% (118/128) of meta-analyses one could not exclude a 2-fold difference in both directions. CONCLUSIONS We identified limited comparative evidence on harms in trials from these two country settings. Substantial differences in the risk point estimates were common; the potential for modest differences could rarely be excluded with confidence.
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Affiliation(s)
- Despina Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5107, USA; Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Ames Building, Room 2A027B, Palo Alto, CA, 94301, USA; Meta-Research Innovation Center at Stanford (METRICS), 1070 Arastradero Road, Palo Alto, CA, 94304, USA.
| | | | - Megan Ancker
- Medecins San Frontieres, 8 Rue Saint-Sabin, Paris 75011, France
| | - Juan N Walterspiel
- Mendocino Coast District Hospital, 700 River Dr, Fort Bragg, CA 95437, USA
| | - Orestis A Panagiotou
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institute of Health, 9609 Medical Center Dr., Room 7E136, Bethesda, MD 20892, USA
| | - Yvonne Maldonado
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305-5107, USA; Department of Health Research and Policy, Stanford University School of Medicine, Redwood Building T152, 150 Governor's Lane, Stanford, CA 94305-5405, USA; Faculty Development and Diversity, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), 1070 Arastradero Road, Palo Alto, CA, 94304, USA; Department of Health Research and Policy, Stanford University School of Medicine, Redwood Building T152, 150 Governor's Lane, Stanford, CA 94305-5405, USA; Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Medical School Office Building, 1265 Welch Road, Stanford, CA 94305, USA; Department of Statistics, Stanford University School of Humanities and Sciences, Sequoia Hall, 390 Serra Mall, Stanford, CA 94305-4065, USA
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16
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Janiaud P, Lajoinie A, Cour-Andlauer F, Cornu C, Cochat P, Cucherat M, Gueyffier F, Kassai B. Different treatment benefits were estimated by clinical trials performed in adults compared with those performed in children. J Clin Epidemiol 2015; 68:1221-31. [PMID: 26164751 DOI: 10.1016/j.jclinepi.2015.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 12/20/2014] [Accepted: 06/29/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Our main objective was to see whether the therapeutic benefit observed in placebo controlled randomized controlled trials (RCTs) is different between adults and children. STUDY DESIGN AND SETTING We searched three electronic databases for meta-analyses that included double-blind, placebo-controlled RCTs with separate results for adults and children. The selected reviews were classified according to disease and drug used. The heterogeneity of treatment response between adults and children was measured using ratio of odds ratios (RORs). RESULTS We selected 89 meta-analyses and calculated RORs for 124 drugs. Heterogeneity in the direction of the treatment effect was observed in one drug and heterogeneity in the quantity of the treatment effect for 13 drugs, indicating significantly different treatment effect in adults when compared with children. RORs were not significantly different from 1 for 110 drugs. For 36 of these drugs, the treatment effect was confirmed in both populations. CONCLUSION We found different treatment benefits estimated by clinical trials performed in adults compared with those performed in children for 14 of 124 drugs. Data on dose adjustment and child age groups from RCTs were not adequately reported to investigate their influence on the treatment benefit dissimilarities.
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Affiliation(s)
| | - Audrey Lajoinie
- Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France
| | - Fleur Cour-Andlauer
- Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France
| | - Catherine Cornu
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France; Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
| | - Pierre Cochat
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Department of Pediatric Nephrology, Hopital Femme Mere Enfant, Lyon, France
| | - Michel Cucherat
- Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
| | - François Gueyffier
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France
| | - Behrouz Kassai
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France; Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France.
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17
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Maruani A, Carriot M, Jonville-Béra AP, Lorette G, Gissot V. [Highlight on clinical research in pediatrics]. Ann Dermatol Venereol 2015; 142:446-9. [PMID: 25934212 DOI: 10.1016/j.annder.2015.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/09/2015] [Accepted: 03/26/2015] [Indexed: 11/25/2022]
Affiliation(s)
- A Maruani
- Unité de dermatologie pédiatrique, service de dermatologie, hôpital Trousseau, université François-Rabelais Tours, CHRU de Tours, avenue de la République, 37044 Tours cedex, France.
| | - M Carriot
- Centre d'investigation clinique, CHRU de Tours, 37044 Tours cedex, France
| | - A-P Jonville-Béra
- Service de pharmacologie clinique, CHRU de Tours, 37044 Tours cedex, France
| | - G Lorette
- Unité de dermatologie pédiatrique, service de dermatologie, hôpital Trousseau, université François-Rabelais Tours, CHRU de Tours, avenue de la République, 37044 Tours cedex, France
| | - V Gissot
- Centre d'investigation clinique, CHRU de Tours, 37044 Tours cedex, France
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18
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Joseph PD, Craig JC, Caldwell PHY. Clinical trials in children. Br J Clin Pharmacol 2015; 79:357-69. [PMID: 24325152 PMCID: PMC4345947 DOI: 10.1111/bcp.12305] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/28/2013] [Indexed: 12/31/2022] Open
Abstract
Safety and efficacy data on many medicines used in children are surprisingly scarce. As a result children are sometimes given ineffective medicines or medicines with unknown harmful side effects. Better and more relevant clinical trials in children are needed to increase our knowledge of the effects of medicines and to prevent the delayed or non-use of beneficial therapies. Clinical trials provide reliable evidence of treatment effects by rigorous controlled testing of interventions on human subjects. Paediatric trials are more challenging to conduct than trials in adults because of the paucity of funding, uniqueness of children and particular ethical concerns. Although current regulations and initiatives are improving the scope, quantity and quality of trials in children, there are still deficiencies that need to be addressed to accelerate radically equitable access to evidence-based therapies in children.
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Affiliation(s)
- Pathma D Joseph
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Jonathan C Craig
- School of Public Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Patrina HY Caldwell
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
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19
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Bialy L, Vandermeer B, Lacaze-Masmonteil T, Dryden DM, Hartling L. A meta-epidemiological study to examine the association between bias and treatment effects in neonatal trials. ACTA ACUST UNITED AC 2014; 9:1052-9. [DOI: 10.1002/ebch.1985] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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20
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Seegers V, Trinquart L, Boutron I, Ravaud P. Comparison of treatment effect estimates for pharmacological randomized controlled trials enrolling older adults only and those including adults: a meta-epidemiological study. PLoS One 2013; 8:e63677. [PMID: 23723992 PMCID: PMC3665786 DOI: 10.1371/journal.pone.0063677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 04/05/2013] [Indexed: 11/29/2022] Open
Abstract
CONTEXT Older adults are underrepresented in clinical research. To assess therapeutic efficacy in older patients, some randomized controlled trials (RCTs) include older adults only. OBJECTIVE To compare treatment effects between RCTs including older adults only (elderly RCTs) and RCTs including all adults (adult RCTs) by a meta-epidemiological approach. METHODS All systematic reviews published in the Cochrane Library (Issue 4, 2011) were screened. Eligible studies were meta-analyses of binary outcomes of pharmacologic treatment including at least one elderly RCT and at least one adult RCT. For each meta-analysis, we compared summary odds ratios for elderly RCTs and adult RCTs by calculating a ratio of odds ratios (ROR). A summary ROR was estimated across all meta-analyses. RESULTS We selected 55 meta-analyses including 524 RCTs (17% elderly RCTs). The treatment effects differed beyond that expected by chance for 7 (13%) meta-analyses, showing more favourable treatment effects in elderly RCTs in 5 cases and in adult RCTs in 2 cases. The summary ROR was 0.91 (95% CI, 0.77-1.08, p = 0.28), with substantial heterogeneity (I(2) = 51% and τ(2) = 0.14). Sensitivity and subgroup analyses by type-of-age RCT (elderly RCTs vs RCTs excluding older adults and vs RCTs of mixed-age adults), type of outcome (mortality or other) and type of comparator (placebo or active drug) yielded similar results. CONCLUSIONS The efficacy of pharmacologic treatments did not significantly differ, on average, between RCTs including older adults only and RCTs of all adults. However, clinically important discrepancies may occur and should be considered when generalizing evidence from all adults to older adults.
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Affiliation(s)
- Valérie Seegers
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
| | - Ludovic Trinquart
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
- Université Paris Descartes – Sorbonne Paris Cité, Paris, France
- French Cochrane Centre, Paris, France
| | - Isabelle Boutron
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
- Université Paris Descartes – Sorbonne Paris Cité, Paris, France
- French Cochrane Centre, Paris, France
| | - Philippe Ravaud
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Paris, France
- INSERM U738, Paris, France
- Université Paris Descartes – Sorbonne Paris Cité, Paris, France
- French Cochrane Centre, Paris, France
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, United States of America
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Bourgeois FT, Murthy S, Pinto C, Olson KL, Ioannidis JP, Mandl KD. Pediatric versus adult drug trials for conditions with high pediatric disease burden. Pediatrics 2012; 130:285-92. [PMID: 22826574 PMCID: PMC3408692 DOI: 10.1542/peds.2012-0139] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Optimal treatment decisions in children require sufficient evidence on the safety and efficacy of pharmaceuticals in pediatric patients. However, there is concern that not enough trials are conducted in children and that pediatric trials differ from those performed in adults. Our objective was to measure the prevalence of pediatric studies among clinical drug trials and compare trial characteristics and quality indicators between pediatric and adult drug trials. METHODS For conditions representing a high burden of pediatric disease, we identified all drug trials registered in ClinicalTrials.gov with start dates between 2006 and 2011 and tracked the resulting publications. We measured the proportion of pediatric trials and subjects for each condition and compared pediatric and adult trial characteristics and quality indicators. RESULTS For the conditions selected, 59.9% of the disease burden was attributable to children, but only 12.0% (292/2440) of trials were pediatric (P < .001). Among pediatric trials, 58.6% were conducted without industry funding compared with 35.0% of adult trials (P < .001). Fewer pediatric compared with adult randomized trials examined safety outcomes (10.1% vs 16.9%, P = .008). Pediatric randomized trials were slightly more likely to be appropriately registered before study start (46.9% vs 39.3%, P = .04) and had a modestly higher probability of publication in the examined time frame (32.8% vs 23.2%, P = .04). CONCLUSIONS There is substantial discrepancy between pediatric burden of disease and the amount of clinical trial research devoted to pediatric populations. This may be related in part to trial funding, with pediatric trials relying primarily on government and nonprofit organizations.
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Affiliation(s)
- Florence T. Bourgeois
- Division of Emergency Medicine and,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Srinivas Murthy
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Catia Pinto
- Public Health Unit, North Lisbon Healthcare Centers, Lisbon, Portugal; and
| | - Karen L. Olson
- Division of Emergency Medicine and,Children’s Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology, Children’s Hospital Boston, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John P.A. Ioannidis
- Stanford Prevention Research Center, Department of Medicine, and,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Kenneth D. Mandl
- Division of Emergency Medicine and,Children’s Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology, Children’s Hospital Boston, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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22
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Williams K, Thomson D, Seto I, Contopoulos-Ioannidis DG, Ioannidis JPA, Curtis S, Constantin E, Batmanabane G, Hartling L, Klassen T. Standard 6: age groups for pediatric trials. Pediatrics 2012; 129 Suppl 3:S153-60. [PMID: 22661762 DOI: 10.1542/peds.2012-0055i] [Citation(s) in RCA: 310] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Katrina Williams
- University of Melbourne, Royal Children’s Hospital and Murdoch Childrens Research Institute, Melbourne, Australia
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23
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Contopoulos-Ioannidis DG, Seto I, Hamm MP, Thomson D, Hartling L, Ioannidis JPA, Curtis S, Constantin E, Batmanabane G, Klassen T, Williams K. Empirical evaluation of age groups and age-subgroup analyses in pediatric randomized trials and pediatric meta-analyses. Pediatrics 2012; 129 Suppl 3:S161-84. [PMID: 22661763 DOI: 10.1542/peds.2012-0055j] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND An important step toward improvement of the conduct of pediatric clinical research is the standardization of the ages of children to be included in pediatric trials and the optimal age-subgroups to be analyzed. METHODS We set out to evaluate empirically the age ranges of children, and age-subgroup analyses thereof, reported in recent pediatric randomized clinical trials (RCTs) and meta-analyses. First, we screened 24 RCTs published in Pediatrics during the first 6 months of 2011; second, we screened 188 pediatric RCTs published in 2007 in the Cochrane Central Register of Controlled Trials; third, we screened 48 pediatric meta-analyses published in the Cochrane Database of Systematic Reviews in 2011. We extracted information on age ranges and age-subgroups considered and age-subgroup differences reported. RESULTS The age range of children in RCTs published in Pediatrics varied from 0.1 to 17.5 years (median age: 5; interquartile range: 1.8-10.2) and only 25% of those presented age-subgroup analyses. Large variability was also detected for age ranges in 188 RCTs from the Cochrane Central Register of Controlled Trials, and only 28 of those analyzed age-subgroups. Moreover, only 11 of 48 meta-analyses had age-subgroup analyses, and in 6 of those, only different studies were included. Furthermore, most of these observed differences were not beyond chance. CONCLUSIONS We observed large variability in the age ranges and age-subgroups of children included in recent pediatric trials and meta-analyses. Despite the limited available data, some age-subgroup differences were noted. The rationale for the selection of particular age-subgroups deserves further study.
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Affiliation(s)
- Despina G Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California 94305, USA.
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24
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Hartling L, Hamm M, Klassen T, Chan AW, Meremikwu M, Moyer V, Scott S, Moher D, Offringa M. Standard 2: containing risk of bias. Pediatrics 2012; 129 Suppl 3:S124-31. [PMID: 22661758 DOI: 10.1542/peds.2012-0055e] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
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Damsted SK, Born AP, Paulson OB, Uldall P. Exogenous glucocorticoids and adverse cerebral effects in children. Eur J Paediatr Neurol 2011; 15:465-77. [PMID: 21632268 DOI: 10.1016/j.ejpn.2011.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 04/15/2011] [Accepted: 05/06/2011] [Indexed: 10/18/2022]
Abstract
Glucocorticoids are commonly used in treatment of paediatric diseases, but evidence of associated adverse cerebral effects is accumulating. The various pharmacokinetic profiles of the exogenous glucocorticoids and the changes in pharmacodynamics during childhood, result in different exposure of nervous tissue to exogenous glucocorticoids. Glucocorticoids activate two types of intracellular receptors, the mineralocorticoid receptor and the glucocorticoid receptor. The two receptors differ in cerebral distribution, affinity and effects. Exogenous glucocorticoids favor activation of the glucocorticoid receptor, which is associated with unfavorable cellular outcomes. Prenatal treatment with glucocorticoids can compromise brain growth and is associated with periventricular leukomalacia, attentions deficits and poorer cognitive performance. In the neonatal period exposure to glucocorticoids reduces neurogenesis and cerebral volume, impairs memory and increases the incidence of cerebral palsy. Cerebral effects of glucocorticoids in later childhood have been less thoroughly studied, but apparent brain atrophy, reduced size of limbic structures and neuropsychiatric symptoms have been reported. Glucocortioids affect several cellular structures and functions, which may explain the observed adverse effects. Glucocorticoids can impair neuronal glucose uptake, decrease excitability, cause atrophy of dendrites, compromise development of myelin-producing oligodendrocytes and disturb important cellular structures involved in axonal transport, long-term potentiation and neuronal plasticity. Significant maturation of the brain continues throughout childhood and we hypothesize that exposure to exogenous glucocorticoids during preschool and school age causes adverse cerebral effects. It is our opinion that studies of associations between exposure to glucocorticoids during childhood and impaired neurodevelopment are highly relevant.
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Affiliation(s)
- Sara K Damsted
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Juliane Marie Center, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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