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Raymond J, Fahed R, Darsaut TE. Ethical Problems of Observational Studies and Big Data Compared to Randomized Trials. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024; 49:389-398. [PMID: 38739037 DOI: 10.1093/jmp/jhae021] [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] [Indexed: 05/14/2024] Open
Abstract
The temptation to use prospective observational studies (POS) instead of conducting difficult trials (RCTs) has always existed, but with the advent of powerful computers and large databases, it can become almost irresistible. We examine the potential consequences, were this to occur, by comparing two hypothetical studies of a new treatment: one RCT, and one POS. The POS inevitably submits more patients to inferior research methodology. In RCTs, patients are clearly informed of the research context, and 1:1 randomized allocation between experimental and validated treatment balances risks for each patient. In POS, for each patient, the risks of receiving inferior treatment are impossible to estimate. The research context and the uncertainty are down-played, and patients and clinicians are at risk of becoming passive research subjects in studies performed from an outsider's view, which potentially has extraneous objectives, and is conducted without their explicit, autonomous, and voluntary involvement and consent.
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Affiliation(s)
- Jean Raymond
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Robert Fahed
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
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Basilio-Flores JE, Aguilar-Melgar JA, Pacheco-Fernandez Baca H. Location-based clinical and angiographic profile of brain arteriovenous malformations - a single-center observational study. Acta Neurochir (Wien) 2024; 166:211. [PMID: 38739281 DOI: 10.1007/s00701-024-06105-y] [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: 01/22/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND The location of brain arteriovenous malformations (bAVM) is one of the most relevant prognostic factors included in surgical, endovascular and radiosurgical scores. However, their characteristics according to location are seldom described. The goal of this study was to describe the clinical and angiographic characteristics of bAVM classified according to their location. METHODS This retrospective observational study included patients diagnosed with bAVM and attending a national referral hospital during the period 2010-2020. Data regarding clinical and angiographic variables were extracted, including characteristics on nidus, arterial afferents, venous drainage and associated aneurysms. BAVM were classified in 8 groups according to their location: frontal, temporal, parieto-occipital, periventricular, deep, cerebellar, brainstem and mixed. Data distribution for each group was determined and between-group differences were assessed. RESULTS A total of 269 bAVM (in 258 patients) were included. The most frequent location was parieto-occipital; and the least frequent, brainstem. Statistically significant differences were observed between groups for most studied variables, including: clinical presentation, functional status at admission; nidus size and density, classification according to the Spetzler-Martin, Buffalo and modified Pollock-Flickinger scales; number, diameter, origin and type of afferents; number, diameter, type and direction of venous drainage, retrograde venous flow; and presence and size of flow-related aneurysms. CONCLUSION The clinical and angiographic differences observed between brain AVM groups allow the formulation of profiles according to their location.
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Affiliation(s)
- Juan E Basilio-Flores
- Department of Neurosurgery, Hospital Nacional Daniel Alcides Carrión, Callao, Peru.
- School of Medicine, National University of San Marcos, Lima, Peru.
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Voon KKR, Lim AAT, Wong HC, Sim YF, Foong KWC. Decision-making patterns among expert and novice orthodontists and oral maxillofacial surgeons in the management of adults with Class III malocclusions and moderate degree of skeletal discrepancies. J Orthod 2023; 50:410-422. [PMID: 37357426 DOI: 10.1177/14653125231181603] [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] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To explore the decision-making patterns among expert and novice orthodontists and oral maxillofacial surgeons in the management of adults with Class III malocclusions and moderate skeletal discrepancies. DESIGN Self-administered questionnaire survey. SETTING Faculty of Dentistry, National University of Singapore and the University Dental Cluster, National University Hospital, Singapore. PARTICIPANTS A total of 55 clinicians, comprising 13 expert orthodontists, 20 novice orthodontists, 10 expert oral maxillofacial surgeons and 12 novice oral maxillofacial surgeons. METHODS Clinicians assessed six adults with a Class III malocclusion and moderate skeletal discrepancy. They were asked to decide who could be managed exclusively by orthodontic camouflage, who would require combined orthodontic-orthognathic surgery as the only viable treatment, or who could be offered both treatment options. RESULTS The study found variable decision-making patterns among the clinicians in each case. Only 18.2%-40.0% of clinicians agreed that the cases selected were of moderate skeletal discrepancies and could be offered both treatment options whereas the rest were either more inclined to recommend orthodontic camouflage or orthognathic surgery. Intra-clinician agreement (n = 20) was only fair (Kappa value = 0.31). There was only slight inter-clinician agreement (n = 55) on their clinical decisions (Kappa value = 0.10). Clinical experience and dental specialty did not significantly influence clinicians' decisions. Oral and maxillofacial surgeons were 1.98 times more likely to indicate orthognathic surgery as the only viable treatment compared to the orthodontists (95% confidence interval = 1.15-3.42). CONCLUSION Variability in the patterns of decision-making for adults with a Class III malocclusion and moderate skeletal discrepancy was observed among the clinicians with low repeatability and agreement.
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Affiliation(s)
| | | | - Hung Chew Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yu Fan Sim
- Faculty of Dentistry, National University of Singapore, Singapore
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Ognard J, Magro E, Caroff J, Bodani V, Mosimann PJ, Gentric JC. Endovascular Management of Brain Arteriovenous Malformations. Semin Neurol 2023; 43:323-336. [PMID: 37276887 DOI: 10.1055/a-2105-6614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVMs) are a rare and potentially life-threatening disease. Despite this, there is only one randomized controlled trial on bAVM management, A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA). The results of the ARUBA trial favor a noninterventional approach in the case of an unruptured bAVM; however, implementation of these findings is challenging in daily practice. Instead, management of bAVM relies on multidisciplinary discussions that lead to patient-specific strategies based on patient preferences, local expertise, and experience in referral centers. Considering the diverse patterns of presentation and numerous treatment modalities, implementing standardized guidelines in this context proves challenging, notwithstanding the recommendations or expert opinions offered. Endovascular treatment (EVT) of bAVM can be curative, or can serve as an adjunct treatment prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e., venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique, and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT for bAVM.
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Affiliation(s)
- Julien Ognard
- Department of Interventional Neuroradiology, Brest University Hospital, Brest, France
- Inserm, UMR 1101 (Laboratoire de Traitement de l'Information Médicale-LaTIM), Université de Bretagne Occidentale, Brest, France
| | - Elsa Magro
- Inserm, UMR 1101 (Laboratoire de Traitement de l'Information Médicale-LaTIM), Université de Bretagne Occidentale, Brest, France
- Department of Neurosurgery, Brest University Hospital, Brest, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Vivek Bodani
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Pascal John Mosimann
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Jean-Christophe Gentric
- Department of Interventional Neuroradiology, Brest University Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Université de Bretagne Occidentale, Brest, France
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Nguyen TN. Management of Unruptured Intracranial Aneurysms and Brain Arteriovenous Malformations. Continuum (Minneap Minn) 2023; 29:584-604. [PMID: 37039411 DOI: 10.1212/con.0000000000001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Managing a patient with an unruptured brain aneurysm or brain arteriovenous malformation (AVM) can lead to uncertainty about preventive treatment. While the bleeding risks are low, the morbidity or mortality associated with a hemorrhagic event is not insignificant. The objective of this article is to review the natural history of these vascular entities, the risk factors for hemorrhage, preventive treatment options, and the risks of treatment. LATEST DEVELOPMENTS Randomized trials to inform preventive treatment strategies for unruptured intracranial aneurysms and brain AVMs are ongoing. Higher angiographic obliteration rates of unruptured intracranial aneurysms have been reported with the flow-diversion technique compared with alternative standard techniques. One randomized trial for unruptured brain AVMs showed a higher rate of morbidity and mortality in patients who underwent interventional treatment compared with observation. ESSENTIAL POINTS The decision to treat a patient with a brain aneurysm should consider patient factors, the patient's life expectancy, aneurysm anatomical factors, and treatment risks. Patients with unruptured brain AVMs should be observed in light of recent clinical trial data or enrolled in an ongoing clinical trial.
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Raymond J, Magro E, Darsaut TE. Understanding burden of proof and equipoise in the design of pragmatic clinical trials: An example from a trial on brain arteriovenous malformations. Neurochirurgie 2022; 68:608-611. [PMID: 35787924 DOI: 10.1016/j.neuchi.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The burden of proof principle is rarely discussed and poorly understood, but central to the proper design of pragmatic clinical trials. A better understanding of the principle could play an important role in the re-introduction of scientific methods within practice and in revising fundamental problems with the current research-care separation. METHODS We analyze the design of the ARUBA trial on the management of unruptured brain arteriovenous malformations. We also review how the concept of clinical equipoise was introduced to address a misconceived problem of research ethics. RESULTS The ARUBA trial hypothesis in favour of conservative management of brain arteriovenous malformations failed to take into account the fact that the burden of proof was on surgery, endovascular treatment or radiation therapy. Thus, results remained inconclusive and other trials are needed. The equipoise notion fails to take into account that the burden of proof is on unvalidated medical or surgical interventions, if we want to provide outcome-based medical care that patients can trust. CONCLUSION The burden of proof principle is essential to properly design pragmatic trials. This principle also explains why in certain circumstances optimal care is a randomized care trial.
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Affiliation(s)
- J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - E Magro
- Service de neurochirurgie, CHU Cavale-Blanche, Inserm UMR 1101 LaTIM, Brest, France
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie Health Sciences Centre, 8440 112St NW, Edmonton, Alberta, Canada
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Fahed R, Darsaut TE, Farzin B, Chagnon M, Raymond J. Measuring clinical uncertainty and equipoise by applying the agreement study methodology to patient management decisions. BMC Med Res Methodol 2020; 20:214. [PMID: 32842953 PMCID: PMC7448326 DOI: 10.1186/s12874-020-01095-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Clinical uncertainty and equipoise are vague notions that play important roles in contemporary problems of medical care and research, including the design and conduct of pragmatic trials. Our goal was to show how the reliability study methods normally used to assess diagnostic tests can be applied to particular management decisions to measure the degree of uncertainty and equipoise regarding the use of rival management options. Methods We first use thrombectomy in acute stroke as an illustrative example of the method we propose. We then review, item by item, how the various design elements of diagnostic reliability studies can be modified in order to measure clinical uncertainty. Results The thrombectomy example shows sufficient disagreement and uncertainty to warrant the conduct of additional randomized trials. The general method we propose is that a sufficient number of diverse individual cases sharing a similar clinical problem and covering a wide spectrum of clinical presentations be assembled into a portfolio that is submitted to a variety of clinicians who routinely manage patients with the clinical problem. Discussion Clinicians are asked to independently choose one of the predefined management options, which are selected from those that would be compared within a randomized trial that would address the clinical dilemma. Intra-rater agreement can be assessed at a later time with a second evaluation. Various professional judgments concerning individual patients can then be compared and analyzed using kappa statistics or similar methods. Interpretation of results can be facilitated by providing examples or by translating the results into clinically meaningful summary sentences. Conclusions Measuring the uncertainty regarding management options for clinical problems may reveal substantial disagreement, provide an empirical foundation for the notion of equipoise, and inform or facilitate the design/conduct of clinical trials to address the clinical dilemma.
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Affiliation(s)
- Robert Fahed
- Division of Neurology, The Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - Tim E Darsaut
- Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, 8440 - 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Behzad Farzin
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier Universitaire de Montréal - CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC, H2X 0C1, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistic, Pavillion André-Aisenstadt, Université de Montréal, PO Box 6218, succursale Centre-ville, Montreal, Quebec, H3C 3J7, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier Universitaire de Montréal - CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC, H2X 0C1, Canada.
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Smajda S, Ciccio G, Fahed R, Robert T, Botta D, Redjem H, Desilles JP, Mazighi M, Zuber K, Escalard S, Baharvahdat H, Blanc R, Chauvet D, Philibert M, Chokron S, Piotin M. Visual Field Defect Before and After Endovascular Treatment of Occipital Arteriovenous Malformations. Neurosurgery 2020; 87:E663-E671. [PMID: 32629471 DOI: 10.1093/neuros/nyaa280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 04/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Occipital arteriovenous malformations (AVMs) carry a high risk of postoperative morbidity because of their anatomic relation to the visual cortex and optic radiations. Data regarding endovascular management of these lesions are scant. OBJECTIVE To report our single-center experience with occipital AVMs, most of which were treated endovascularly, with a special interest for postoperative visual impairment. METHODS From a prospective database, we assessed the clinical and radiological data of all patients with an occipital AVM managed between 1997 and 2018. The extension of the nidus to the primary visual cortex was assessed and correlated to the pre- and postintervention visual symptomatology. Modified Rankin Scale and visual fields (VFs) were assessed pre- and post-treatment and at the last follow-up. RESULTS A total of 83 patients (47 males [56.6%]) with an occipital AVM were included in the study. Mean age at presentation was 33.5 ± 15.0 yr (min-max = 7-76). A total of 34 patients (41%) presented with hemorrhage related to the AVM. A total of 57 patients (68.7%) underwent endovascular treatment (EVT) alone, 20 (24.1%) underwent embolization and surgery, 3 (3.6%) underwent embolization and radiosurgery, and 3 (3.6%) were conservatively managed. A complete obliteration of the AVM was achieved in 53 patients (66.3%). A post-treatment worsening of the VF was found in 24 of the treated patients (30%), 3 patients (9%) for ruptured AVMs, and in 21 patients (46%) for unruptured AVMs. Morbidity rate was 3.7% and mortality rate was 2.5%. CONCLUSION EVT of occipital AVM carries a non-negligible rate of complications, especially regarding visual functions.
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Affiliation(s)
- Stanislas Smajda
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Gabriele Ciccio
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Robert Fahed
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France.,Department of Medicine (Neurology), Ottawa Hospital Research Institute & University of Ottawa, Ottawa, Canada
| | - Thomas Robert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Civico di Lugano, Lugano, Switzerland.,University of Southern Switzerland, USI, Lugano, Switzerland
| | - Daniele Botta
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | | | - Mikael Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Kevin Zuber
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Humain Baharvahdat
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Dorian Chauvet
- Department of Neurosurgery, Fondation Rothschild Hospital, Paris, France
| | - Manon Philibert
- Department of Neuro-Ophtalmology, Fondation Rothschild Hospital, Paris, France
| | - Sylvie Chokron
- Unité Vision et Cognition, Fondation Rothschild Hospital, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
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Magro E, Gentric JC. Brain AVM management: Anything new under the sun? J Neuroradiol 2019; 47:3-4. [PMID: 31836205 DOI: 10.1016/j.neurad.2019.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Elsa Magro
- LaTIM Inserm UMR 1101, UBO, Neurosurgery department, Brest university Hospital, 29609 Brest, France
| | - Jean-Christophe Gentric
- EA GETBO, EA 3878 UBO, Radiology Department, Brest university Hospital, 29609 Brest, France.
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Measuring clinical uncertainty as a preliminary step to randomized controlled trials. J Clin Epidemiol 2019; 112:96-98. [DOI: 10.1016/j.jclinepi.2019.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/11/2019] [Accepted: 04/11/2019] [Indexed: 11/18/2022]
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Fahed R, Darsaut TE, Mounayer C, Chapot R, Piotin M, Blanc R, Mendes Pereira V, Abud DG, Iancu D, Weill A, Roy D, Nico L, Nolet S, Gevry G, Raymond J. Transvenous Approach for the Treatment of cerebral Arteriovenous Malformations (TATAM): Study protocol of a randomised controlled trial. Interv Neuroradiol 2019; 25:305-309. [PMID: 30843441 PMCID: PMC6547200 DOI: 10.1177/1591019918821738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Transvenous embolisation is a promising technique but the benefits remain uncertain. We hypothesised that transvenous embolisation leads to a higher rate of arteriovenous malformation angiographic occlusion than transarterial embolisation. METHODS The Transvenous Approach for the Treatment of cerebral Arteriovenous Malformations (TATAM) is an investigator initiated, multicentre, prospective, phase 2, randomised controlled clinical trial. To test the hypothesis that transvenous embolisation is superior to transarterial embolisation for arteriovenous malformation obliteration, 76 patients with arteriovenous malformations considered curable by up to two sessions of endovascular therapy will be randomly allocated 1:1 to treatment with either transvenous embolisation (with or without transarterial embolisation) (experimental arm) or transarterial embolisation alone (control arm). The primary endpoint of the trial is complete arteriovenous malformation occlusion, assessed by catheter cerebral angiography. Complete occlusions will be confirmed at 3 months, while incompletely occluded arteriovenous malformations, considered treatment failures, will then be eligible for complementary treatments by surgery, radiation therapy, or even transvenous embolisation. Standard procedural safety outcomes will also be assessed. Patient selection will be validated by a case selection committee, and participating centres with limited experience in transvenous embolisation will be proctored. DISCUSSION The TATAM trial is a transparent research framework designed to offer a promising but still unvalidated treatment to selected arteriovenous malformation patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT03691870.
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Affiliation(s)
- Robert Fahed
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Tim E Darsaut
- Department of Surgery, University of
Alberta Hospital, Edmonton, Canada
| | - Charbel Mounayer
- Service de Neuroradiologie, CHU
Dupuytren, Service de Neuroradiologie, Limoges, France
| | - René Chapot
- Department of Neuroradiology,
Alfried-Krupp Krankenhaus Hospital, Essen, Germany
| | - Michel Piotin
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Raphaël Blanc
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Daniel G Abud
- Division of Interventional
Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo,
Brazil
| | - Dana Iancu
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Lorena Nico
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Suzanne Nolet
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
| | - Guylaine Gevry
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
| | - Jean Raymond
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
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The 2018 ter Brugge Lecture: Problems with the Introduction of Innovations in Neurovascular Care. Can J Neurol Sci 2019; 46:151-158. [PMID: 30786939 DOI: 10.1017/cjn.2018.391] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Most endovascular innovations have been introduced into clinical care by showing good outcomes in small enthusiastic case series of selected patients. Randomized clinical trials (RCTs) have rarely been performed, except for acute ischemic stroke, but even then most trial designs were too explanatory to inform clinical decisions. In this article, we review 2 × 2 tables and forest plots that summarize RCT results to examine methodological issues in the design and interpretation of clinical studies. Research results can apply in practice when RCTs are all-inclusive, pragmatic trials. Common problems include the following: (i) using restrictive eligibility criteria in explanatory trials, instead of including the diversity of patients in need of care, which hampers future generalizability of results; (ii) ignoring an entire line of the 2 × 2 table and excluding patients who do not meet the proposed criteria of a diagnostic test in its evaluation (perfusion studies) which renders clinical inferences misleading; (iii) ignoring an entire column of the 2 × 2 table and comparing different patients treated using the same treatment instead of different treatments in the same patients (the "wrong axis" comparisons of prognostic studies and clinical experience) which leads to unjustified treatment decisions and actions; or (iv) combining all aforementioned problems (case series and epidemiological studies). The most efficient and reliable way to improve patient outcomes, after as well as long before research results are available, is to change the way we practice: to use care trials to guide care in the presence of uncertainty.
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Raymond J, Magro E, Darsaut T. Clinical research training integrated to practice in neurosurgery and interventional neuroradiology. Neurochirurgie 2018; 64:391-394. [DOI: 10.1016/j.neuchi.2018.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/12/2018] [Accepted: 08/30/2018] [Indexed: 11/25/2022]
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Ognard J, Magro E, Caroff J, Ben Salem D, Andouard S, Nonent M, Gentric JC. A new time-resolved 3D angiographic technique (4D DSA): Description, and assessment of its reliability in Spetzler-Martin grading of cerebral arteriovenous malformations. J Neuroradiol 2017; 45:177-185. [PMID: 29274362 DOI: 10.1016/j.neurad.2017.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The Spetzler and Martin (SM) cerebral arteriovenous malformation (AVM) classification is a widely used 5-tier classification. This common language allows specialists to exchange about AVMs and must be reliably characterized by the imaging methods. We presented an agreement study on a new method of digital subtracted 3D rotational angiography resolved in time (four-dimensional DSA: 4D DSA) compared to the gold standard (two-dimensional DSA: 2D DSA) in AVM grading using the SM classification. METHODS Ten patients with AVMs were included during one year, they had an angiographic exploration with both 4D DSA and 2D DSA. Three readers assessed the SM classification. One reader conducted a second reading. The inter-, intra-observer and intermodality agreements were calculated by Kappas. Dose to patient was reported. RESULTS Considering the SM grade, the inter-observer agreement between 4D DSA and 2D DSA was equivalent (κ=0.45 and 0.46), and calculated as substantial κ=0.76 between the 2 methods. The agreement between 4D DSA and 2D DSA was calculated as moderate κ=0.46 assessing the size of the nidus, slight κ=0.18 analyzing the drainage and almost perfect κ=0.95 depicting the localization. 4D DSA performed during a standard initial angiographic assessment of AVM represented approximately 6% of the total dose. CONCLUSION The addition of this new technique 4D DSA could be performed regularly in addition to the 2D DSA if available, to assess SM grading, with an acceptable exposure to ionizing radiation.
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Affiliation(s)
- Julien Ognard
- Service d'imagerie médicale, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France; Inserm UMR 1101, laboratoire de traitement de l'information médicale (LaTIM), 5, avenue Foch, 29200 Brest cedex, France.
| | - Elsa Magro
- Inserm UMR 1101, laboratoire de traitement de l'information médicale (LaTIM), 5, avenue Foch, 29200 Brest cedex, France; Service de neurochirurgie, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
| | - Jildaz Caroff
- Service de neuroradiologie interventionnelle, hôpital Bicêtre, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Douraied Ben Salem
- Service d'imagerie médicale, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France; Inserm UMR 1101, laboratoire de traitement de l'information médicale (LaTIM), 5, avenue Foch, 29200 Brest cedex, France
| | - Sebastien Andouard
- SIEMENS S.A.S. Division Healthcare, service application, 40, avenue des Fruitiers, 93200 Saint-Denis, France
| | - Michel Nonent
- Service d'imagerie médicale, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France; Groupe d'étude de la thrombose occidentale, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
| | - Jean-Christophe Gentric
- Service d'imagerie médicale, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France; Groupe d'étude de la thrombose occidentale, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
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