External validity of randomised controlled trials: "to whom do the results of this trial apply?"

Sociodemographic variables are rarely included in femoral neck fracture randomized controlled trials: A systematic review

Introduction

Sociodemographic factors may affect outcomes after surgery for patients with femoral neck fractures. The purpose of this study was to assess the inclusion of sociodemographic variables in high-impact randomized controlled trials (RCTs) related to femoral neck fracture operative management.

Methods

PubMed, Embase, and Medline were queried from January 1, 2017 to March 31, 2024 for RCTs pertaining to operative treatment of femoral neck fracture patients in high impact journals were included. The journal of publication, year of publication, and interventions assessed by the RCTs were extracted. Each RCT was assessed for inclusion of the following sociodemographic variables: age, sex/gender, body mass index (BMI)/weight, race/ethnicity, education level, insurance, smoking/tobacco use, socioeconomic status, marital status, alcohol use, English proficiency, geographic measures (i.e. proximity to hospital), employment status, and prefracture residence status. Temporal reporting trends were analyzed using Chi-square test.

Results

Of 1038 RCTs identified, 37 were included for analysis. All 37 studies reported age and sex/gender. BMI/weight was reported in 22 studies (59.5 %). Patients' prefracture residence status was reported in 11 studies (29.7 %). Smoking/tobacco use was reported in 9 studies (24.3 %). Race/ethnicity was reported in only 5 studies (13.5 %). Socioeconomic status, English proficiency, geographic measures, marital status, education level, insurance, and employment variables were all reported in less than 10 % of the analyzed RCTs. Furthermore, there was no significant difference in the proportion of studies reporting at least one sociodemographic variable (excluding age, sex/gender, and BMI/weight) in 2017-2020 (10/22) versus 2021-2024 (8/15; p = 0.743).

Conclusion

Our analysis of high-impact RCTs revealed a large gap in the reporting of sociodemographic variables. RCTs relating to femoral neck fracture management should consistently report key sociodemographic variables to ensure generalizability of study findings.

Level of evidence

1.

Over-the-counter products for insomnia in adults: A scoping review of randomised controlled trials

BACKGROUND

Insomnia is highly prevalent and poses significant personal and socio-economic challenges. While the National Institute for Health and Care Excellence (NICE) recommendations define possible medical approaches, over-the-counter products are commonly used to self-manage insomnia symptoms. This scoping review aims to determine the size and scope of the evidence-base regarding the effectiveness and safety of over-the-counter products for insomnia symptoms in adults.

METHODS

The electronic databases of CENTRAL, MEDLINE, EMBASE, PsycINFO, and AMED were searched from inception to December 19th, 2022, for all randomised controlled trials evaluating over-the-counter products compared to placebo, in adults aged 18-65 with insomnia symptoms. Results were synthesised descriptively.

RESULTS

51 randomised controlled trials were included, evaluating herbal products (n = 34), dietary supplements (n = 15), herbal-dietary combinations (n = 4), and over-the-counter medicines (n = 2). Sample sizes ranged between 10 and 405 participants. Eleven studies were conducted in participants with co-morbidities. Interventions were most frequently given as monotherapy and compared against placebo. Most studies (n = 41) demonstrated interventions' positive effects on insomnia symptoms. Among the most studied products, valerian and melatonin have substantial evidence to demonstrate their effectiveness and safety. Promising products demonstrating benefits compared with prescription medication alone included: valerian; lemon balm and fennel; and valerian, hops, and passionflower. Intervention-related side effects were mostly mild and transient. No serious adverse events were reported across all studies.

CONCLUSIONS

Over-the-counter products show promising, but inconclusive findings in alleviating insomnia symptoms in adults. Future research should focus on investigating products currently used in real life, consider economic evaluations, and be evaluated in populations with co-morbidities and ethnic minorities, to better guide clinical advice.

Cross-institutional validation of a polar map-free 3D deep learning model for obstructive coronary artery disease prediction using myocardial perfusion imaging: insights into generalizability and bias

PURPOSE

Deep learning (DL) models for predicting obstructive coronary artery disease (CAD) using myocardial perfusion imaging (MPI) have shown potential for enhancing diagnostic accuracy. However, their ability to maintain consistent performance across institutions and demographics remains uncertain. This study aimed to investigate the generalizability and potential biases of an in-house MPI DL model between two hospital-based cohorts.

METHODS

We retrospectively included patients from two medical centers in Taiwan who underwent stress/redistribution thallium-201 MPI followed by invasive coronary angiography within 90 days as the reference standard. A polar map-free 3D DL model trained on 928 MPI images from one center to predict obstructive CAD was tested on internal (933 images) and external (3234 images from the other center) validation sets. Diagnostic performance, assessed using area under receiver operating characteristic curves (AUCs), was compared between the internal and external cohorts, demographic groups, and with the performance of stress total perfusion deficit (TPD).

RESULTS

The model showed significantly lower performance in the external cohort compared to the internal cohort in both patient-based (AUC: 0.713 vs. 0.813) and vessel-based (AUC: 0.733 vs. 0.782) analyses, but still outperformed stress TPD (all p < 0.001). The performance was lower in patients who underwent treadmill stress MPI in the internal cohort and in patients over 70 years old in the external cohort.

CONCLUSIONS

This study demonstrated adequate performance but also limitations in the generalizability of the DL-based MPI model, along with biases related to stress type and patient age. Thorough validation is essential before the clinical implementation of DL MPI models.

Are participants in gout medication registration clinical trials representative of people with gout in the general population?

BACKGROUND

Ensuring clinical trial participants are representative of the target population is important for the generalizability of trial findings. This study aimed to determine if phase 3 clinical trials of gout medications approved by the US Food and Drug Administration (FDA) included participants representative of the US general population with gout.

METHODS

Gout therapeutics were identified by searching the FDA and CenterWatch websites. Data from phase 3 clinical trials of FDA approved gout medications between 2009 and 2023 were analyzed. Demographic variables (sex, age, and ethnicity) and comorbidities (hypertension, myocardial infarction, heart failure, nephrolithiasis, chronic kidney disease, BMI ≥30 kg/m2, and diabetes) were extracted and compared with published data from the 2007-2008 and 2015-2016 US National Health and Nutrition Examination Survey (NHANES). Data were pooled using a random effects model and presented as a percentage with a 95 % confidence interval.

RESULTS

Twelve phase 3 clinical trials were included, covering febuxostat, colchicine, pegloticase, lesinurad, and canakinumab. Compared to the NHANES gout population, clinical trials over-represented men, younger individuals, and White ethnicity participants. Under-representation was observed for clinical trial participants with hypertension, prior myocardial infarction, nephrolithiasis, and diabetes, while those with a BMI ≥30 kg/m2 were over-represented.

CONCLUSIONS

FDA approved gout medication trials since 2009 have not enrolled a study population that is representative of the US general population with gout, particularly regarding age, ethnicity, and cardiometabolic comorbidities. For broader applicability, future phase 3 trials should ensure the greater inclusion of women, older individuals, diverse ethnicities, and those with common gout-associated comorbid conditions.

Advancing Principled Pharmacoepidemiologic Research to Support Regulatory and Healthcare Decision Making: The Era of Real-World Evidence

A compilation of factors over the past decade-including the availability of increasingly large and rich healthcare datasets, advanced technologies to extract unstructured information from health records and digital sources, advancement of principled study design and analytic methods to emulate clinical trials, and frameworks to support transparent study conduct-has ushered in a new era of real-world evidence (RWE). This review article describes the evolution of the RWE era, including pharmacoepidemiologic methods designed to support causal inferences regarding treatment effects, the role of regulators and other health authorities in establishing distributed real-world data networks enabling analytics at scale, and the many global guidance documents on principled methods of producing RWE. This article also highlights the growing opportunity for RWE to support decision making by regulators, health technology assessment groups, clinicians, patients, and other stakeholders and provides examples of influential RWE studies. RWE holds promise to address important questions that clinical trials typically do not answer about treatment benefits and risks, and to ultimately impact public health by helping to guide decision making across the healthcare ecosystem.

INTEGRATING A RANDOMIZED CONTROLLED TRIAL WITH A PARALLEL OBSERVATIONAL COHORT STUDY IN CERVICAL SPINE SURGERY INSIGHTS FROM THE FORAMINOTOMY ACDF COST-EFFECTIVENESS TRIAL (FACET)

BACKGROUND CONTEXT

In most randomized controlled trials (RCT), data is primarily and often only available for individuals who have agreed to be randomized, with little, if any, consideration for those who elected not to participate.

PURPOSE

This study evaluated the value of including a concurrent observational cohort of patients who declined randomization in the Foraminotomy ACDF Cost-Effectiveness Trial (FACET-RCT) but still underwent anterior or posterior cervical surgery. The goal was to determine if the FACET-RCT results could be generalized by comparing baseline characteristics and clinical outcomes between the randomized trial and observational cohort.

STUDY DESIGN/SETTING

A nationwide RCT with a parallel observational cohort recruiting patients from routine care.

PATIENT SAMPLE

Between January 2016 and May 2020, 389 patients with cervical radiculopathy were screened, and 358 were eligible. Of these, 265 (74%) were randomized in the FACET-RCT for either posterior or anterior cervical surgery, while 80 (22%) opted out of randomization and were followed in an observational cohort. Only 13 (4%) patients declined participation in both FACET-RCT and cohort.

OUTCOME MEASURES

Demographic data was collected, and primary outcomes included treatment success, evaluated using the Odom criteria as well as reduction in arm pain, assessed with a Visual Analogue Scale (VAS) at 6 weeks, and every 6 months up to 2 years post-surgery. Secondary outcomes included VAS for neck pain, neck disability, work ability, quality of life, treatment satisfaction, and need for revision surgeries.

METHODS

Baseline characteristics were compared between the FACET-RCT and cohort using logistic regression. Primary and secondary outcomes were analyzed for differences between study designs using mixed-model analyses adjusted for confounders. The primary noninferiority endpoint of the FACET-RCT was evaluated in both the cohort and combined data from both cohort and FACET-RCT at 2 years of follow-up.

RESULTS

Patients in the cohort were slightly younger than those in the FACET-RCT (mean age of 48.4 versus 51.2 years; mean difference [MD], -2.5; 95% confidence interval [CI], -4.8 to -0.2; p=0.04). In sub-analyses stratified by surgical approach (anterior vs. posterior surgery), fewer patients in the observational cohort who underwent posterior surgery reported severe neck pain at baseline compared to their counterparts in the FACET-RCT (OR, 0.38; 95% CI: 0.14 to 0.92; p=0.04). No other significant baseline differences were found. No significant differences in treatment success (OR, 1.3; 95% CI: 0.3 to 6.0; p=0.75) and arm pain reduction (MD, -3.9; 95% CI: -9.2 to 1.5; p=0.16) were observed between study designs. The primary noninferiority endpoint was achieved in the combined data from both the cohort and FACET-RCT, with a narrower CI compared to the FACET-RCT alone, indicating a more robust result. Secondary outcomes were comparable between groups.

CONCLUSIONS

Randomization did not influence clinical outcomes for cervical surgery patients. Combining RCT with the observational cohort increased statistical power, external validity and robustness. Our findings support the value of observational methods as a complement to RCTs, especially when a large number of patients refuse RCT participation and high dropout and crossover rates are expected.

Generalizability of trial criteria on amyloid-lowering therapy against Alzheimer's disease to individuals with mild cognitive impairment or early Alzheimer's disease in the general population

Treatment with anti-amyloid-β monoclonal antibodies slowed cognitive decline in recent RCTs in patients with mild cognitive impairment (MCI) and early dementia due to Alzheimer's disease (AD). However, stringent trial eligibility criteria may affect generalisability to clinical practice. We extracted eligibility criteria for trials of aducanumab, lecanemab and donanemab, and applied these to participants with MCI and early clinical AD dementia from the population-based Rotterdam Study. Participants underwent questionnaires, genotyping, brain-MRI, cognitive testing, and cardiovascular assessment. We determined amyloid status using a validated prediction model based on age and APOE-genotype. Of 968 participants (mean age: 75 years, 56% women), 779 had MCI and 189 dementia. Across trials, around 40% of participants would be ineligible because of predicted amyloid negativity. At least one clinical exclusion criterion was present in 76.3% of participants for aducanumab, 75.8% for lecanemab, and 59.8% for donanemab. Common criteria were cardiovascular disease (35.2%), anticoagulant (31.2%), psychotropic or immunological medication use (20.4%), anxiety or depression (15.9%), or lack of social support (15.6%). One-third were ineligible based on brain-MRI findings alone, similar across trials and predominantly due to cerebral small-vessel disease. Combining amyloid, clinical, and imaging criteria, eligibility ranged from 9% (95% CI:7.0-11.1) for aducanumab, 8% (6.2-9.9) lecanemab to 15% (12.4-17.5) for donanemab. Findings from recent RCTs reporting protective effects of monoclonal antibodies against amyloid-β are applicable to less than 15% of community-dwelling individuals with MCI or early AD. These findings underline that evidence for drug efficacy and safety is lacking for the vast majority of patients with MCI/AD in routine clinical practice.

The target trial framework in global health research: barriers and opportunities

A randomised trial is the best way to make causal inferences when evaluating the effectiveness and safety of health interventions in global health research. Trials, however, are inherently expensive, unfeasible in many scenarios, and may raise ethical issues. In these scenarios, we must turn to analyses of observational data to learn what works. The target trial framework provides an organising principle for the design of observational studies that can lead to clinically interpretable results and analytic approaches that can reduce common biases. In this analysis, we describe the global distribution of data sources used in applications of the target trial framework and discuss barriers to its increased use in global health research, such as limited access to high-quality observational data. We then suggest a cost-effective solution of incorporating the collection of additional high-quality observational data into the implementation of large randomised trials in low- and middle-income countries. We found that the target trial framework is underutilised in observational studies conducted in most low- and middle-income countries. The main barriers are little available data and few trained researchers, which can be overcome by incorporating high-quality observational data collection into the data collection phase of large randomised trials, and by introducing small adjustments to the teaching curriculum.

A Real-World Study on the Use, Effectiveness, and Safety of Esketamine Nasal Spray in Patients with Treatment-Resistant Depression: INTEGRATE Study

INTRODUCTION

The INTEGRATE study aimed to provide information on the use, effectiveness, and safety of esketamine nasal spray (ESK-NS) for the treatment of treatment-resistant depression (TRD) in real-world practice in Spain.

METHODS

This was an observational, cross-sectional, retrospective study conducted in adults aged 18-74 years who met the criteria for TRD. The weekly impact of ESK-NS on depressive symptoms was evaluated by clinical judgment using four categories (nonresponse, response, remission, not available). The onset of action 24 h after administration was also evaluated. Information on adverse events was collected from the medical records.

RESULTS

We included 196 patients, of whom 189 were considered evaluable; the mean (SD) number of previous episodes was 3.7 (3.0). According to the investigator's judgment, 152 (80.4%) of 189 patients were in response or remission in the induction phase, and 54 (90%) of 60 during the maintenance phase. The proportions of patients in remission were 9.5%, 18.7%, and 38.3% during the induction, optimization, and maintenance phases, respectively. Fifty-three (28.0%) patients experienced an improvement in depressive symptoms within the first 24 h after the first administration of ESK-NS. Most adverse events reported with ESK-NS were mild and did not require any action with the study drug; the number of adverse events decreased over time, especially during the first 4 weeks.

CONCLUSION

Consistent with the available evidence, the results of this study indicate that ESK-NS is an effective and safe option to consider within the therapeutic algorithm for TRD.

Waiver of informed consent in clinical research: a summary of contemporary guidelines and a resource for researchers

OBJECTIVE

Low-risk pragmatic clinical research such as learning health system research, quality assurance activities and comparative effectiveness studies are approaches to embedding clinical research within routine practice to generate generalisable evidence. Individual written informed consent may present a barrier to the feasibility and inclusiveness of such low-risk clinical research. Within an overarching moral and ethical framework, the form and requirements of consent vary in both clinical practice and research settings according to the context and level of risk. Within some low-risk research settings, waiver of consent may be appropriate.

ANALYSIS

We sought to describe contemporary national and international English-language guidelines pertaining to the use and oversight of waiver of consent in clinical research. We identify 14 guidelines including 1 international, 1 regional and 12 national statements, and summarise the principles in each for circumstances in which a waiver of consent is appropriate.

CONCLUSION

While complete international harmonisation of policy may be neither realistic nor necessary, there are numerous unifying concordances suggesting a broad consensus on the approach to waiver of consent research.

Low LDL-cholesterol drives the risk of bleeding in patients treated with aspirin: A 15-year study in a real-world large population

We aimed to investigate the link between LDL cholesterol (LDL-C) levels and hemorrhage risk over an extended period, both in subjects taking aspirin and in individuals not receiving any antiplatelet agent. We calculated the predicted adjusted relative hazard of bleeding by LDL-C concentration for the whole cohort and the aspirin-treated subgroup. The study included 39,784 individuals with a mean follow-up of 14.9 years, totaling over 500,000 patient-years. Across the cohort, 3380 bleeding events were reported, with a higher incidence in patients with LDL-C < 70 mg/dL compared to those with LDL-C ≥ 70 mg/dL (9.9 % vs 8.4 %). In aspirin-treated patients, multivariable analysis revealed that hemorrhagic events were significantly associated with aging, male sex, body mass index, hypertension, and LDL-C < 70 mg/dL. These patients had a significantly lower event-free survival probability if their LDL-C was < 70 mg/dL compared to ≥ 70 mg/dL. Low LDL-C values were a significant risk factor (HR >1) while higher LDL-C values were protective (HR <1). A stepwise increase of 10 mg/dL in LDL-C from < 30 to ≥ 200 mg/dL was associated with a decreasing trend for bleeding events in both the entire cohort and the aspirin-treated subgroup. This is the first report specifically addressing the relationship between LDL-C levels and bleeding risk in a population receiving low-intensity antithrombotic therapy. Our data demonstrate that in patients taking aspirin, LDL-C levels below 70 mg/dL significantly increase the risk of bleeding, with major implications for long-term cardiovascular risk management.

Do trial benefits predict real-world gains in metastatic castration resistant prostate cancer

BACKGROUND

It is important to understand the relationship between drug efficacy measured in randomized clinical trials (RCTs) and real-world drug effectiveness. We estimate how RCT overall survival (OS) and RCT radiographic progression-free survival (rPFS) benefits predict the association between treatments and real-world OS gains for metastatic castration-resistant prostate cancer (mCRPC) drugs.

METHODS

Using the National Cancer Institute list of approved cancer drugs and the National Comprehensive Cancer Network Treatment Guidelines, we identified all pharmaceutical therapies for mCRPC approved between 2010 and 2019. We obtained RCT OS and rPFS hazard ratios from the pivotal trials used for Food and Drug Administration (FDA) approval, and we estimated real-world OS hazard ratios using the Optum Clinformatics Extended DataMart Databases. We modeled real-world OS hazard ratios as a function of both RCT OS and RCT rPFS hazard ratios using Cox proportional hazards regressions, adjusted for year of diagnosis, age, race, and Elixhauser Comorbidity Index.

RESULTS

When we did not account for nonrandom real-world selection of patients into receiving a newly approved therapy (ie, "treatment selection bias"), real-world OS gains were 15% lower than associated RCT OS and RCT rPFS benefits. However, after accounting for treatment selection bias in real-world settings, real-world OS gains were almost 28% greater than RCT OS and RCT rPFS benefits. Association between treatment and OS gains increased the longer a new therapy was on the market.

CONCLUSIONS

After adjusting for treatment selection bias, RCT OS and RCT rPFS estimates serve as useful, or even conservative, predictors of RW OS gains.

Analysis of eligibility criteria clusters based on large language models for clinical trial design

OBJECTIVES

Clinical trials (CTs) are essential for improving patient care by evaluating new treatments' safety and efficacy. A key component in CT protocols is the study population defined by the eligibility criteria. This study aims to evaluate the effectiveness of large language models (LLMs) in encoding eligibility criterion information to support CT-protocol design.

MATERIALS AND METHODS

We extracted eligibility criterion sections, phases, conditions, and interventions from CT protocols available in the ClinicalTrials.gov registry. Eligibility sections were split into individual rules using a criterion tokenizer and embedded using LLMs. The obtained representations were clustered. The quality and relevance of the clusters for protocol design was evaluated through 3 experiments: intrinsic alignment with protocol information and human expert cluster coherence assessment, extrinsic evaluation through CT-level classification tasks, and eligibility section generation.

RESULTS

Sentence embeddings fine-tuned using biomedical corpora produce clusters with the highest alignment to CT-level information. Human expert evaluation confirms that clusters are well structured and coherent. Despite the high information compression, clusters retain significant CT information, up to 97% of the classification performance obtained with raw embeddings. Finally, eligibility sections automatically generated using clusters achieve 95% of the ROUGE scores obtained with a generative LLM prompted with CT-protocol details, suggesting that clusters encapsulate information useful to CT-protocol design.

DISCUSSION

Clusters derived from sentence-level LLM embeddings effectively summarize complex eligibility criterion data while retaining relevant CT-protocol details. Clustering-based approaches provide a scalable enhancement in CT design that balances information compression with accuracy.

CONCLUSIONS

Clustering eligibility criteria using LLM embeddings provides a practical and efficient method to summarize critical protocol information. We provide an interactive visualization of the pipeline here.

Getting prepared for the silver wave: challenges in conducting rheumatic and musculoskeletal disease research in older adults

Research in older adults diagnosed with rheumatic and musculoskeletal diseases (RMDs) comes with unique challenges, as these patients often face consequences of ageing, such as multimorbidity, polypharmacy, and geriatric syndromes (eg, frailty). In this viewpoint, we highlight various clinical, ethical, regulatory and logistical challenges, including, among others, issues with the decision-making capacity of older adults regarding study participation. We emphasise the need for feasible strategies and protocols to enhance research inclusivity in order to ultimately improve evidence-based care for the growing population of older adults with RMDs.

Benefit from dose-dense adjuvant chemotherapy for breast cancer: subgroup analyses from the randomised phase 3 PANTHER trial

Background

It is unclear whether some patients with high-risk breast cancer do not warrant adjuvant dose-dense chemotherapy due to small expected absolute benefit.

Methods

The phase 3 PANTHER trial (NCT00798070) compared adjuvant sequential epirubicin/cyclophosphamide (EC) and docetaxel (D) administered in either tailored dose-dense (tDD EC/D) or standard interval schedule (FEC/D) to patients with high-risk resected early breast cancer (n = 2003). We compared outcomes across key subgroups of interest, evaluated the performance of the online prognostication and treatment benefit estimation tool PREDICT and conducted a subpopulation treatment effect pattern plot (STEPP) analysis. Primary endpoint was breast cancer recurrence free survival (BCRFS).

Findings

Median follow-up was 10.3 years. Treatment with tDD EC/D improved 10-year BCRFS across all subgroups including according to menopausal status, with an absolute benefit of 2% or more, as well as in luminal (Hazard Ratio [HR] = 0.83, 95% Confidence Interval [CI] 0.65-1.05) and Human Epidermal Growth Factor Receptor 2 (HER2) positive (HR = 0.53, 95% CI 0.30-0.93), but not triple negative breast cancer patients (HR = 1.02, 95% CI 0.66-1.57). PREDICT underestimated overall survival in the entire population and across all subgroups. In STEPP analysis, absolute benefit from tDD EC/D in BCRFS was stable across risk-defined subpopulations, from 3.8% in the lowest risk patients to 3.6% in the highest risk ones. There was no differential treatment effect over time.

Interpretation

We could not reliably identify any subgroup not benefiting from dose-dense treatment, which should be considered for patients with primary resected high-risk breast cancer.

Funding

Cancerfonden, Bröstcancerförbundet, Radiumhemmets Forskningsfonder, Amgen, Roche, sanofi-aventis.

Evaluating generalizability of oncology trial results to real-world patients using machine learning-based trial emulations

Randomized controlled trials (RCTs) evaluating anti-cancer agents often lack generalizability to real-world oncology patients. Although restrictive eligibility criteria contribute to this issue, the role of selection bias related to prognostic risk remains unclear. In this study, we developed TrialTranslator, a framework designed to systematically evaluate the generalizability of RCTs for oncology therapies. Using a nationwide database of electronic health records from Flatiron Health, this framework emulates RCTs across three prognostic phenotypes identified through machine learning models. We applied this approach to 11 landmark RCTs that investigated anti-cancer regimens considered standard of care for the four most prevalent advanced solid malignancies. Our analyses reveal that patients in low-risk and medium-risk phenotypes exhibit survival times and treatment-associated survival benefits similar to those observed in RCTs. In contrast, high-risk phenotypes show significantly lower survival times and treatment-associated survival benefits compared to RCTs. Our results were corroborated by a comprehensive robustness assessment, including examinations of specific patient subgroups, holdout validation and semi-synthetic data simulation. These findings suggest that the prognostic heterogeneity among real-world oncology patients plays a substantial role in the limited generalizability of RCT results. Machine learning frameworks may facilitate individual patient-level decision support and estimation of real-world treatment benefits to guide trial design.

Suhexiang pill for acute ischemic stroke in real-world practice setting (SUNRISE): protocol of a multicenter registry

BACKGROUND

Suhexiang (SHX) pill is widely used for treating acute ischemic stroke (AIS). Experimental and randomized controlled trials suggested that SHX pill was beneficial for patients with AIS. However, the effectiveness of SHX pill in real-world practice setting remains unclear. It is of great importance to investigate the effectiveness and safety of SHX pill in patients with acute ischemic stroke in real-world clinical practice with long-term follow-up.

METHODS

The Suhexiang pill for acute ischemic stroke in Real-world Practice Setting (SUNRISE) is a multicenter, prospective, product-specific, observational study designed to provide insight into the administration of SHX pill for patients with AIS in the real-world clinical practice setting, with an initial sample size of 1000. Eligible patients treated with SHX pill within seven days of AIS onset will be consecutively included in this registry. The primary outcome is the proportion of patients independent at 3 months after stroke onset defined by an mRS score of 0, 1, or 2.

CONCLUSION

The findings of the SUNRISE registry will not only provide insights into the characteristics of patients who may benefit from SHX treatment, but also may enable the individualized treatment decision-making of SHX pill in real-world practice setting.

STUDY REGISTRATION

This study was registered with the ClinicalTrials.gov (URL: https://clinicaltrials.gov/ , Unique identifier: NCT05833932).

Computational Phenomapping of Randomized Clinical Trials to Enable Assessment of their Real-world Representativeness and Personalized Inference

BACKGROUND

Randomized clinical trials (RCTs) define evidence-based medicine, but quantifying their generalizability to real-world patients remains challenging. We propose a multidimensional approach to compare individuals in RCT and electronic health record (EHR) cohorts by quantifying their representativeness and estimating real-world effects based on individualized treatment effects (ITE) observed in RCTs.

METHODS

We identified 65 pre-randomization characteristics of an RCT of heart failure with preserved ejection fraction (HFpEF), the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT), and extracted those features from patients with HFpEF from the EHR within the Yale New Haven Health System. We then assessed the real-world generalizability of TOPCAT by developing a multidimensional machine learning-based phenotypic distance metric between TOPCAT stratified by region including the United States (US) and Eastern Europe (EE) and EHR cohorts. Finally, from the ITE identified in TOPCAT participants, we assessed spironolactone benefit within the EHR cohorts.

RESULTS

There were 3,445 patients in TOPCAT and 8,121 patients with HFpEF across 4 hospitals. Across covariates, the EHR patient populations were more similar to each other than the TOPCAT-US participants (median SMD 0.065, IQR 0.011-0.144 vs median SMD 0.186, IQR 0.040-0.479). At the multi-variate level using the phenotypic distance metric, our multidimensional similarity score found a higher generalizability of the TOPCAT-US participants to the EHR cohorts than the TOPCAT-EE participants. By phenotypic distance, a 47% of TOPCAT-US participants were closer to each other than any individual EHR patient. Using a TOPCAT-US-derived model of ITE from spironolactone, all patients were predicted to derive benefit from spironolactone treatment in the EHR cohort, while a TOPCAT-EE-derived model predicted 13% of patients to derive benefit.

CONCLUSIONS

This novel multidimensional approach evaluates the real-world representativeness of RCT participants against corresponding patients in the EHR, enabling the evaluation of an RCT's implication for real-world patients.

Emulation of ARISTOTLE and ROCKET AF trials in real-world atrial fibrillation patients results in similar efficacy and safety as original landmark trials: insights from the GARFIELD-AF registry

AIMS

This study aimed to determine the robustness, reproducibility and representativeness of the landmark Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (AF) (ARISTOTLE) and Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in AF (ROCKET AF) randomised trials through replication in an observational AF patient registry.

METHODS AND RESULTS

Patients from the Global Anticoagulant Registry in the FIELD (GARFIELD)-AF registry treated with apixaban, rivaroxaban or vitamin K antagonist (VKA) were assessed for eligibility for the ARISTOTLE and ROCKET AF trials. HRs of apixaban and rivaroxaban versus comparator for stroke/systemic embolism, major bleeding and all-cause mortality within 2 years follow-up were calculated using propensity score overlap-weighted Cox models. Among GARFIELD-AF patients on apixaban, 2570/3615 (71%) would have been eligible for ARISTOTLE. Among patients using rivaroxaban, 2005/4914 (41%) would have been eligible for ROCKET AF. Eligibility rates were steady over time, with minor differences across medical specialties. Real-world AF patients selected according to trial criteria had lower cardiovascular burden than the original trial participants, especially compared with ROCKET AF. HRs (95% CI) for apixaban versus VKA among ARISTOTLE-eligible users were 0.57 (0.34 to 0.94) for stroke/systemic embolism, 0.76 (0.48 to 1.20) for major bleeding and 0.89 (0.70 to 1.12) for all-cause mortality. Among ROCKET AF-eligible rivaroxaban users, HRs for rivaroxaban versus VKA were 0.90 (0.57 to 1.43), 0.92 (0.59 to 1.43) and 0.86 (0.69 to 1.08), respectively. All safety and efficacy estimates were similar to those in the original trials.

CONCLUSION

Real-world representativeness of the selection criteria was greater for ARISTOTLE than ROCKET AF. The pivotal randomised trials of apixaban and rivaroxaban versus warfarin can be successfully emulated in real-world AF patients by applying trial-specific selection criteria and appropriate methodology for non-randomised treatment allocation.

TRIAL REGISTRATION NUMBER

NCT01090362.

The value of local validation of a predictive model. A nomogram for predicting failure of non-invasive ventilation in patients with SARS-COV-2 pneumonia

OBJECTIVE

We aimed to determine predictors of non-invasive ventilation (NIV) failure and validate a nomogram to identify patients at risk of NIV failure.

DESIGN

Observational, analytical study of a retrospective cohort from a single center, compared with an external cohort (March 2020 to August 2021).

SETTING

Two intensive care units (ICUs).

PATIENTS

Patients with pneumonia due to severe acute respiratory syndrome (SARS-CoV-2) and NIV > 24 h (154 and 229 in each cohort).

INTERVENTIONS

The training cohort identified NIV failure predictors. A nomogram, created via logistic regression, underwent validation with the Hosmer-Lemeshow (HL), calibration curve and test and area under the curve (AUC). Its external validity was tested using AUC.

MAIN VARIABLES OF INTEREST

Demographics, comorbidities, severity scores, NIV settings, vital signs, blood gases, and oxygenation at the start and 24 h after NIV, NIV failure.

RESULTS

NIV failure was 37.6% and 18% in the training and validation cohorts, respectively. Risk factors for NIV failure inluded age, obesity, sequential organ failure assessment (SOFA) score at admission, and heart rate (HR) and heart rate, acidosis, consciousness, oxygenation, respiratory rate (HACOR) 24 h post-NIV. The model's HL test result was 0.861, with an AUC of 0.89 (confidence interval [CI] 0.839-0.942); validation AUC was 0.547 (CI 0.449-0.645).

CONCLUSIONS

A predictive model using age, obesity, SOFA score, HR, and HACOR at 24 h predicts NIV failure in our COVID-19 patients but may not apply to other ICUs.

Remote Lifestyle Intervention to Reduce Postpartum Weight Retention: Protocol for a Community-Engaged Hybrid Type I Effectiveness-Implementation Randomized Controlled Trial

BACKGROUND

Maternal obesity is associated with significant racial disparities. People who identify as non-Hispanic Black and Latinx are at the highest risk related adverse short- and long-term health outcomes (eg, hypertension in pregnancy and postpartum weight retention). Remote lifestyle interventions delivered during and after pregnancy hold promise for supporting healthy weight outcomes; however, few are tested in groups of people who self-identify as non-Hispanic Black and Latinx or address the neighborhood-level and psychosocial factors driving maternal health disparities. Implementing remote lifestyle interventions within community-based programs that serve birthing people may optimize trust and engagement, promote scalability and sustainability, and have the broadest public health impact.

OBJECTIVE

The goal of this trial is to test the effectiveness of a culturally adapted remote lifestyle intervention (Healthy for Two-Home Visiting) implemented within home visiting compared to usual home visiting services on postpartum weight retention among pregnant or postpartum individuals, in particular those who identify as non-Hispanic Black and Latinx. Facilitators and barriers to implementation of the intervention within home visiting will be examined.

METHODS

We describe the rationale and protocol for this hybrid type I effectiveness-implementation randomized controlled trial. In this paper, we highlight the community-engaged approach and trial design features that enable the implementation of the intervention within home visiting and demonstrate its applicability to the target population. Participants will be 360 pregnant individuals with overweight or obesity enrolled between 20 and 33 weeks of gestation and randomized 1:1 to Healthy for Two-Home Visiting or usual home visiting services. The primary outcome is weight retention at 6 months post partum, calculated as 6-month postpartum weight minus earliest pregnancy weight (≤18 wk of gestation). The measures of implementation include intervention feasibility, acceptability, reach, adoption, and fidelity. Throughout the paper, we highlight the community input used to improve intervention effectiveness and study implementation and as a strategy to promote maternal health equity.

RESULTS

This study was funded in June 2021, and recruitment began in April 2023. As of November 2024, we enrolled 90 participants. Data collection to assess the intervention's effectiveness is expected to end in June 2026. Implementation evaluation is expected to conclude in December 2026.

CONCLUSIONS

This hybrid type I effectiveness-implementation randomized controlled trial integrates a culturally adapted remote lifestyle intervention into early home visiting services to examine its effectiveness on postpartum weight retention compared to usual home visiting. We anticipate that the study results will enable an understanding of the drivers of successful implementation within a community-based setting to maximize the future sustainability and dissemination of a strategy for reducing long-term obesity and other maternal health disparities.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05619705; https://clinicaltrials.gov/study/NCT05619705.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/62847.

Characteristics of eligible patients with knee osteoarthritis accepting versus declining participation in a randomised trial investigating the effect of weight loss versus knee arthroplasty to explore generalisability: A cross-sectional study

BACKGROUND

The INtensive diet versus Knee Arthroplasty (INKA) trial is a randomised trial assessing weight loss as an alternative to knee arthroplasty (KA) in obese patients with severe knee osteoarthritis (OA) awaiting KA (NCT05172843). The external validity of the INKA trial may be hampered if the patients who participate differ from those who decline participation.

OBJECTIVE

To compare baseline characteristics between patients who enrol in the INKA trial and those who decline participation (i.e., non-INKA [nINKA] group).

METHODS

We applied a cross-sectional study design, collecting and comparing baseline characteristics among all patients eligible for enrolment in the INKA trial from two clinics in Copenhagen. Imbalance between accepting (INKA) and declining (nINKA) groups was assessed using standardised differences (StdDs). We were prespecified that StdD values < 0.20 would indicate a clinically insignificant imbalance between groups, whereas values > 0.80 indicate incomparability.

RESULTS

Of the 913 patients scheduled for KA, 888 were screened for INKA trial eligibility. Of the 217 eligible patients, 92 (42%) were enroled in the INKA trial, while 37 (17%) participated in the nINKA cross-sectional sample only. Patients enroled in INKA had on average a less severe Oxford knee score (OKS) of 22.0 (standard deviation = 6.7) compared to declining participants in nINKA with 18.6 (7.2), corresponding to an StdD of 0.50, and an absolute difference of 3.45 (95% confidence interval = 0.64-6.26, p = 0.017). A consistent similar pattern was noted across all secondary patient-reported outcomes applied in the INKA trial.

CONCLUSIONS

We observed discrepancies in patient-reported outcomes, with those who declined enrolment reporting more severe symptoms. These differences, however, were below the minimally important difference between groups for OKS, which is set to 4.84 points.

LEVEL OF EVIDENCE

Level II-III cross-sectional study in a randomised control trial.

Eligibility Criteria of Randomized Clinical Trials in Critical Care Medicine

Importance

Eligibility criteria for randomized clinical trials (RCTs) are designed to select clinically relevant patient populations. However, not all eligibility criteria are strongly justified, potentially excluding marginalized groups, and limiting the generalizability of trial findings.

Objective

To summarize and evaluate the justification of exclusion criteria in published RCTs in critical care medicine.

Evidence Review

A systematic sampling review of parallel-group RCTs published in the top 5 general internal medicine journals by impact factor (The Lancet, New England Journal of Medicine, Journal of the American Medical Association, British Medical Journal, and Annals of Internal Medicine) between January 1, 2018, and February 23, 2023, was conducted. RCTs enrolling adults in intensive care units (ICUs) and RCTs enrolling critically ill patients who required life-sustaining interventions typically initiated in the ICU were included. All study exclusion criteria were categorized as either poorly justified, potentially justified, or strongly justified, adapting previously established criteria, independently and in duplicate.

Findings

In total, 225 studies were identified, 75 of which were included. The median (IQR) number of exclusion criteria per trial was 19 (14-24), with 1455 total exclusion criteria. Common exclusion criteria were related to the risk of adverse reaction to interventions (302 criteria [20.8%]), followed by inability to obtain consent (120 criteria [8.2%]), and treatment limitation decisions (97 criteria [6.7%]). Most exclusion criteria were either strongly justified (1080 criteria [74.2%]) or potentially justified (297 criteria [20.4%]), whereas 5.4% (78 criteria) were poorly justified. Of the 78 poorly justified exclusion criteria, the most common were pregnancy (19 criteria [24.4%]), communication barriers (11 criteria [14.1%]), lactation (10 criteria [12.8%]), and lack of health insurance (10 criteria [12.8%]). Overall, 45 of 75 studies (60.0%) had at least 1 poorly justified exclusion criteria.

Conclusions and Relevance

Most exclusion criteria in critical care medicine RCTs were strongly justifiable. Across poorly justified criteria, the most common exclusions were pregnant or lactating persons, those with communication barriers, and individuals without health insurance. This highlights the need to carefully consider exclusion criteria when designing trials to minimize the inappropriate exclusion of participants and enhance generalizability.

Understanding statistical populations and inferences

BACKGROUND

The term population is frequently used in clinical research and statistics, but concepts are multiple and confusing. Populations are a roundabout way of conceiving classifications, generalizations and inductive inferences. When misapplied, the term can lead to serious errors in study design, analysis and interpretation.

METHODS

We review various notions of populations, their relationship with statistical inferences, and whether they refer to persons, variables or theoretical constructions.

RESULTS

There are design- and model-based statistical inferences. The simplest design-based inference is from a representative random sample to a real definite population, but it is rarely possible or even pertinent in clinical research. The term population rarely concerns patients. Super-populations are theoretical postulates of statistical models that attempt to explain the distributions and relationships of variables. Pseudo-populations are mathematical constructs used to balance baseline characteristics to extract causal inferences from observational studies. Statistical populations are as numerous as variables. This leads to an explosion of entities, with much room for divergent analyses and manipulations. Target populations are to whom study results should apply. In the absence of a real population, they are erroneously assimilated to the eligibility criteria of study subjects. The inductive problem remains unsolved, for inferences from study subjects to future patients then depend on the meaning of words used in indefinite descriptions.

CONCLUSION

The term population often hides more than it reveals regarding problems of generalizations and inferences. Because the term leads to errors and misconceptions, it should rarely be used in clinical research.

Equitable Representation of Pregnant and Lactating Women in Clinical Research: A Historical Review and Critical Analysis of Proposed Legislation

A long history of policymaking and regulation constructed for the purpose of ensuring adequate fetal and infant protections has inadvertently sanctioned the widespread exclusion of pregnant and lactating patients from biomedical research, leaving a paucity of high quality data necessary for clinical decision-making. Although well-intended, the regulatory classification of pregnant women as "vulnerable," in conjunction with burdensome enrollment criteria and other factors weighing against broad inclusion, have ultimately placed the health and safety of these women and their babies in jeopardy. Robust measures are urgently needed to overcome patient and physician reluctance, address substantial evidence gaps, and rectify long-standing disparities which precipitate disproportionately poor health outcomes among this population. In February 2023, the Advancing Safe Medications for Moms and Babies Act of 2023 (the Act) was introduced in the United States House of Representatives with the overarching goal of enabling pregnant and lactating women to achieve equitable participation in clinical research and contribute to developing important biomedical knowledge to guide and improve health care delivered to these patients. This review discusses the historical influence of federal human subject protection regulations on the health and clinical treatment of pregnant and lactating women, outlines and critically analyzes the provisions incorporated into the Act, and reflects on the potential long-term impact the Act would have should it be successful in becoming law. KEY POINTS: · Pregnant and lactating patients are widely excluded from clinical research.. · Evidence guiding the treatment of these patients is limited and of unacceptably low quality.. · Proposed legislation seeks to rectify disparities and empower these patients through improved representation in research..

PRECIS-2 used as an implementation science tool for global environmental health: A cross-sectional evaluation of the Ecolectivos study protocol to reduce burning of household plastic waste in rural Guatemala

BACKGROUND

Randomized controlled trials (RCTs) that evaluate the efficacy of an intervention remain underutilized in community-based environmental health research. RCTs that use a pragmatic design emphasize the effectiveness of interventions in complex, real world settings. Pragmatic trials may be especially relevant when community-based interventions address social and environmental determinants that threaten health equity. The revised Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) is a validated tool developed in 2015 by trialists to ensure that clinical trials are designed to fit their intended purpose, with an assessment of applicability of the trial results to specific contexts. The purpose of this cross-sectional study was to ask Ecolectivos study investigators and external implementation scientists to evaluate the Ecolectivos study protocol using the PRECIS-2 tool prior to the launch of the trial. Ecolectivos is an implementation science study, using a village-level cluster randomized controlled trial design, to assess a behavioral intervention to reduce household plastic waste burning in rural Guatemala.

METHODS

We invited 60 researchers to participate in an online survey between February 2022 and January 2023. Respondents were asked to review the Ecolectivos study protocol and provide scores for the nine PRECIS-2 domains (eligibility, recruitment, setting, organization, flexibility-delivery, flexibility-adherence, follow-up, primary outcome, and primary analysis), with short responses explaining their score. The PRECIS-2 tool is used to assess the degree of pragmatism, ranked on a five-point Likert scale from very explanatory (Checkley W, 2022) to very pragmatic (Ashcraft LE, 2024). Descriptive statistics were used to compare responses between Ecolectivos investigators and external evaluators.

RESULTS

Twenty-five respondents provided data. Among the nine domains, four were rated as pragmatic-eligibility, setting, flexibility-delivery, and primary analysis. Four were evaluated to be equally pragmatic as explanatory-recruitment, organization, flexibility-adherence, and primary outcome. One domain was primarily explanatory in nature-follow-up. Only one domain, eligibility, was statistically significantly different between Ecolectivos investigators and external evaluators, demonstrating that the two groups were broadly consistent in their opinions in eight of the nine study domains. Using the PRECIS-2 tool, we found that our study protocol was viewed as more pragmatic than explanatory, providing evidence to support the pragmatic approach of the Ecolectivos study goals, which is to reduce burning of plastic waste and plastic use in community settings using a behavioral intervention.

CONCLUSIONS

By evaluating the degree of pragmatism within the nine domains, PRECIS-2 guides investigators to think about the applicability of potential results. Investigator assessment and communication regarding intervention protocols for community-level environmental interventions, their degree of pragmatism, and external validity are important for identifying strategies to address complex community problems. Our findings contribute to the growing body of literature that addresses greater research utility through pragmatic trial design, tying community environmental health interventions to the rigor of implementation science strategies.

Strategies to improve recruitment in mental health clinical trials: a scoping review (RE-MIND study)

BACKGROUND

Lower-than-expected recruitment continues to be one of the major causes of trial delays, and trials to improve mental health are no exception. Indeed, recruitment challenges in trials of vulnerable populations, such as those living with mental health illness, can even be exacerbated. To address this, researchers are turning to digital and online recruitment strategies, e.g. web-based approaches and multi-media in order to (1) increase recruitment efficiency (recruit to target and on time) and (2) improve diversity in mental health clinical trials to be more inclusive and reduce health inequity. There is, however, inconclusive evidence on the success of digital and online recruitment strategies in mental health clinical trials. The RE-MIND study comprised a scoping review to assess the impact of using such recruitment strategies in mental health clinical trials to inform a more systematic scoping review.

METHODS

A cohort of 191 recently published RCTs and randomised feasibility studies were identified from the NIHR Journals Library and top two mental health journals (based on citation metrics), Lancet Psychiatry and JAMA Psychiatry. Population characteristics including gender, ethnicity and age were summarised for inclusivity using descriptive statistics, and recruitment strategies were compared to examine differences in their success in recruiting to target.

RESULTS

After screening, 97 articles were included for review. The review findings showed no evidence that offline or mixed strategies were superior for achieving recruitment targets in mental health trials. However, there was a suggestion that trials using a mixed recruitment strategy improved inclusivity and tended to recruit closer to the target.

CONCLUSIONS

The key finding was that consideration should be given to a mixed methods approach to recruitment not only to enable wider and more diverse participation in mental health trials but also to realize greater efficiency.

Attrition and discontinuation in amyotrophic lateral sclerosis clinical trials: a meta-analysis

OBJECTIVES

Attrition due to adverse events and disease progression impacts the integrity and generalizability of clinical trials. The aim of this study is to provide evidence-based estimates of attrition for clinical trials in amyotrophic lateral sclerosis (ALS), and identify study-related predictors, through a comprehensive systematic review and meta-analysis.

METHODS

We systematically reviewed the literature to identify all randomized, placebo-controlled clinical trials in ALS and determined the number of patients who discontinued the study per randomized arm. Subsequently, we meta-analyzed attrition rates across studies, evaluated the difference between study arms, and explored the impact of study-level characteristics. Finally, a meta-regression model predicting study discontinuation for future clinical trials was translated into a web application.

RESULTS

In total, 60 randomized placebo-controlled clinical trials were included in the meta-analysis, randomizing 14,493 patients with ALS. Attrition varied significantly between studies, ranging from 3.1% to 75.7% of all randomized patients, with a pooled effect of 32.0% (90% prediction interval 6.1% to 66.3%). Attrition was similar between the intervention and placebo arm (odds ratio 1.08, 95% CI 0.89 to 1.31, p = 0.43). The follow-up duration was identified as the sole study-level predictor (0.032, 95% CI 0.026 to 0.039, p < 0.001), resulting in predicted attrition of 19.3% for 6-month, 36.4% for 12-month, and 55.6% for 18-month clinical trials.

CONCLUSIONS

ALS clinical trials encounter high attrition, which increases with the follow-up duration. These findings underscore the need to refine our strategies to manage attrition, preserving the integrity and generalizability of ALS clinical trials.

Real-world effects of antidepressants for depressive disorder in primary care: population-based cohort study

BACKGROUND

Antidepressants' effects are established in randomised controlled trials (RCTs), but not in the real world.

AIMS

To investigate real-world comparative effects of antidepressants for depression and compare them with RCTs.

METHOD

We performed a cohort study based on the QResearch database. We included people with a newly recorded diagnosis of depression, exposed to licensed antidepressants in the UK. We assessed all-cause dropouts (acceptability), dropouts for adverse events (tolerability), occurrence of at least one adverse event (safety), and response and remission on the Patient Health Questionnaire (PHQ)-9 (effectiveness) at 2 and 12 months. Logistic regressions were used to compute adjusted-odds ratio (aOR) with 99% CIs, assessing the associations between exposure to each antidepressant against fluoxetine (comparator) and outcomes of interest. We compared estimates from the real world with RCTs using ratio-of-odds ratio (ROR) with 95% CI.

RESULTS

A total of 673 177 depressed people were studied: females 57.1%, mean age 42.8 (s.d. 17.7) years, mean baseline PHQ-9 17.1 (s.d. 5.0) (moderately severe depression). At 2 months, antidepressant acceptability was 61.4%, tolerability 94.4%, safety 54.5%, PHQ-9 decreased to 12.3 (s.d. 6.5). At 12 months, acceptability was 12.3%, tolerability 87.5%, safety 28.8%, PHQ-9 12.9 (s.d. 6.8). In the short and long term, tricyclics, mirtazapine and trazodone were worse than fluoxetine for most outcomes; citalopram had better acceptability than fluoxetine (aOR 0.95; 99% CI 0.92, 0.97), sertraline had lower tolerability (aOR 1.12; 99% CI 1.06, 1.18), and both citalopram and sertraline had lower safety (aOR 1.17 and 1.25, respectively). In the long term, citalopram had better acceptability (aOR 0.78; 99% CI 0.76, 0.81) and effectiveness (aOR 1.12 for both response and remission), but worse tolerability (aOR 1.09; 99% CI 1.06, 1.13) and safety (aOR 1.12; 99% CI 1.08, 1.16). Observational and randomised data were similar for citalopram and sertraline, while there was some difference for drugs less prescribed in the real world.

CONCLUSIONS

Antidepressants showed low acceptability, moderate-to-high tolerability and safety, and small-to-moderate effectiveness in the real world. Real-world and RCT estimates showed similar findings only when the analyses were carried out using large datasets; otherwise, the results diverged.

Spatiotemporal, kinematic and kinetic gait characteristics in Parkinson's disease compared to healthy individuals: A systematic review with meta-analysis

BACKGROUND

Gait disorders are frequently reported in individuals with Parkinson's disease (PD). Despite extensive research, the specific gait features affected by PD remain inadequately defined. Therefore, this study aimed to investigate kinematic, kinetic, and spatiotemporal parameters of gait in individuals with PD compared to healthy controls.

METHODS

We conducted a systematic review in PubMed, CINAHL, and EMBASE up to March 2024 to retrieve studies assessing adults with PD, which examined gait compared to healthy controls. Two reviewers independently performed the screening process, extrapolation data and quality assessment. Studies were meta-analyzed using original units of measurement (mean difference, MD) to enhance the clinical understanding of the gait characteristics. The level of evidence was provided.

FINDINGS

Thirty-four studies were included (n = 1533 participants with PD and n = 1093 healthy controls). Moderate-to-strong evidence was found for reduced speed (MD:-0.21 m/s, 95 %CI: -0.27; -0.15), stride length (MD:-0.17 m, 95 %CI: -0.25; -0.09), swing time (MD:-1.16 % of gait cycle, 95 %CI: -2.30; -0.02), and sagittal range of motion of the lower limb joints in individuals with PD (hip: MD:-5.39°, 95 %CI: -10.42; -0.37; knee: MD:-11.05°, 95 %CI: -21.88; -0.22; ankle: MD:-4.03°, 95 %CI: -6.37; -1.69). An increase in double support time (MD:0.07 s, 95 %CI: 0.05; 0.10) and a decrease in cadence (MD: -4.93 steps/min, 95 %CI: -7.89; -1.98) were observed. Kinetic data showed diverse outcomes, making a meta-analysis not possible.

INTERPRETATION

PD is associated with changes in gait kinematics and spatiotemporal parameters, while kinetic aspects remain under investigated. Future research should focus on kinetics, joint angular velocity, and push-off parameters. PROSPERO registration: CRD42022347368.

Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With vs Without Premorbid Disability in a National Registry

Background and Objectives

Given the paucity of high-quality safety/efficacy data on acute stroke therapies in patients with premorbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), associated workflow, and poststroke outcomes among patients with vs without premorbid disability.

Methods

We used national registry data on thrombolysis/EVT for the Czech Republic from 1 January 2016 to 31 December 2020. Premorbid disability was defined as prestroke modified Rankin Scale score (mRS) ≥3. We compared proportions of patients with vs without premorbid disability who received EVT and examined workflow times. We compared ΔmRS-change in mRS from prestroke to 3 months-in patients with vs without premorbid disability, in addition to intracerebral hemorrhage (ICH), mortality, and discharge NIHSS (National Institutes of Health Stroke Scale score), adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score weighting (PSW) and matching for differences in treatment assignment. We stratified by age group (<65, 65-74, 75-84, ≥85 years) to explore outcome heterogeneity with vs without premorbid disability.

Results

Among 22,405 patients with ischemic stroke who received thrombolysis/EVT/both, 1,712 (7.6%) had prestroke mRS ≥ 3. Patients with prestroke disability were less likely to receive EVT vs those without (10.1% vs 20.7%, aOR: 0.30, 95% CI 0.24-0.36). When treated, they had longer door-to-arterial puncture times (median: 75 minutes, IQR: 58-100 vs 54, IQR: 27-77, adjusted difference: 12.5, 95% CI 2.68-22.3). Patients with prestroke disability receiving thrombolysis/EVT/both had worse ΔmRS (adjusted rate ratio, aIRR on PSW: 1.57, 95% CI 1.43-1.72), rates of 3-month mRS 5-6, discharge NIHSS, and mortality (aOR-PSW [mortality]: 2.54, 95% CI 1.92-3.34), while ICH did not significantly differ. 32.1% of patients with prestroke disability receiving thrombolysis/EVT/both successfully returned to prestroke state, but this proportion ranged from 19.6% for those older than 85 years to 66.0% for those younger than 65 years. Regardless of premorbid disability, EVT was associated with better outcomes including lower ΔmRS (aIRR-PSW: 0.87, 95% CI 0.83-0.91) and mortality, with no interaction of treatment effect by premorbid disability status (e.g., mortality pinteraction = 0.73). EVT recipients with premorbid disability did not differ significantly for several outcomes including ΔmRS (aIRR: 0.99, 95% CI 0.84-1.17) but were more likely to have 3-month mRS 5-6 (70.1% vs 39.5% without premorbid disability, aOR: 1.85, 95% CI 1.12-3.04).

Discussion

Patients with premorbid disability were less likely to receive EVT, had slower treatment times, and had worse outcomes compared with patients without premorbid disability. However, regardless of premorbid disability, patients fared better with EVT vs medical management and one-third with prestroke disability returned to their prestroke status.

Reporting of comorbidities and health status of participants in clinical trials testing amyloid- and tau-targeting monoclonal antibodies for Alzheimer's disease: A systematic review

BACKGROUND

Controversies exist around the external validity of clinical trials on disease-modifying treatments for Alzheimer's disease (AD). Detailed information on the clinical characteristics of research participants is lacking, hampering the understanding of their representativeness.

OBJECTIVE

This study aimed to systematically review the baseline comorbidities and health status of patients with AD enrolled in clinical trials.

METHODS

A systematic review of scientific and gray literature was conducted. Randomized controlled trials, enrolling participants in the AD continuum, and testing amyloid- and tau-targeting monoclonal antibodies were selected. Data on the type of study and intervention and the baseline clinical characteristics of participants were extracted. The proportion of studies reporting information on comorbidities, integrative measures of health (e.g., number of chronic diseases and multimorbidity, frailty, and gait speed), and non-neurological concomitant therapies of participants was calculated.

RESULTS

Thirty-six articles, referring to 41 studies (21,952 participants) were included. None of the retained trials provided information on the comorbidities or other integrative measures reflecting the baseline health status of participants. Only three studies reported data on non-neurological concomitant therapies. Five documents providing relevant information were identified through gray literature searches covering the websites of regulatory agencies and pharmaceutical manufacturers.

CONCLUSIONS

The health characteristics of patients with AD included in randomized controlled trials are poorly reported. Therefore, the external validity of the study findings cannot be fully appreciated.

Mobile Stroke Unit Management in Patients With Acute Ischemic Stroke Eligible for Intravenous Thrombolysis

Importance

Clinical trials have suggested that prehospital management in a mobile stroke unit (MSU) improves functional outcomes in patients with acute ischemic stroke who are potentially eligible for intravenous thrombolysis, but there is a paucity of real-world evidence from routine clinical practice on this topic.

Objective

To determine the association between prehospital management in an MSU vs standard emergency medical services (EMS) management and the level of global disability at hospital discharge.

Design, Setting, and Participants

This was a retrospective, observational, cohort study that included consecutive patients with a final diagnosis of ischemic stroke who received either prehospital management in an MSU or standard EMS management between August 1, 2018, and January 31, 2023. Follow-up ended at hospital discharge. The primary analytic cohort included those who were potentially eligible for IV thrombolysis. A separate, overlapping cohort including all patients regardless of diagnosis was also analyzed. Patient data were obtained from the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Program, a nationwide, multicenter quality assurance registry. This analysis was completed in May 2024.

Exposure

Prehospital management in an MSU (vs standard EMS management).

Main Outcomes and Measures

The primary efficacy end point was the utility-weighted modified Rankin Scale (UW-mRS) score. The secondary efficacy end point was independent ambulation status. The coprimary safety end points were symptomatic intracranial hemorrhage (sICH) and in-hospital mortality.

Results

Of 19 433 patients (median [IQR] age, 73 [62-83] years; 9867 female [50.8%]) treated at 106 hospitals, 1237 (6.4%) received prehospital management in an MSU. Prehospital management in an MSU was associated with a better score on the UW-mRS at discharge (adjusted mean difference, 0.03; 95% CI, 0.01-0.05) and a higher likelihood of independent ambulation at discharge (53.3% [468 of 878 patients] vs 48.3% [5868 of 12 148 patients]; adjusted risk ratio [aRR], 1.08; 95% CI, 1.03-1.13). There was no statistically significant difference in sICH (5.2% [57 of 1094] vs 4.2% [545 of 13 014]; aRR, 1.30; 95% CI, 0.94-1.75]) or in-hospital mortality (5.7% [70 of 1237] vs 6.2% [1121 of 18 196]; aRR, 1.03; 95% CI, 0.78-1.27) between the 2 groups.

Conclusions and Relevance

Among patients with acute ischemic stroke potentially eligible for intravenous thrombolysis, prehospital management in an MSU compared with standard EMS management was associated with a significantly lower level of global disability at hospital discharge. These findings support policy efforts to expand access to prehospital MSU management.

The immediate effects of mobilization with movement on shoulder range of motion and pain in patients with rotator cuff-related shoulder pain: A randomized controlled trial (Evolution Trial)

BACKGROUND

Mobilization with movement (MWM) is commonly used to treat patients with rotator cuff-related shoulder pain (RCRSP). However, the evidence supporting MWM efficacy for improving range of motion (ROM) and pain in patients with RCRSP is limited.

OBJECTIVES

To assess the immediate effects of MWM on the angular onset of pain in patients with RCRSP.

METHODS

Sixty-three participants with RCRSP were randomized to receive 3 sets of 10 repetitions of MWM or sham MWM with a minute rest between each set. The angular onset of pain (primary outcome), and pain intensity at rest and during shoulder abduction to the onset of pain were measured at baseline, and after receiving the 1st and 3rd sets of 10 repetitions of interventions. Other secondary outcomes were measured at baseline and after receiving 3 sets of 10 repetitions of interventions or 1, 2, 3, 5, and 7 days after interventions.

RESULTS

Compared with the sham MWM group, the MWM group had an additional improvement of 6.5° (95% CI -0.9, 13.9) and 13.7° (95% CI 6.3, 21.1) (from baseline) after receiving the 1st and 3rd sets of 10 repetitions of interventions, respectively.

CONCLUSION

MWM improves the angular onset of pain after 3 sets of 10 repetitions of MWM in patients with RCRSP. This study provides preliminary support for the use of MWM in treating patients with RCRSP and provides some guidance for clinicians to decide the MWM dosage to be used in clinical practice.

Characteristics of non-randomised studies of drug treatments: cross sectional study

ABSTRACT

Objective

To examine the characteristics of comparative non-randomised studies that assess the effectiveness or safety, or both, of drug treatments.

Design

Cross sectional study.

Data sources

Medline (Ovid), for reports published from 1 June 2022 to 31 August 2022.

Eligibility criteria for selecting studies

Reports of comparative non-randomised studies that assessed the effectiveness or safety, or both, of drug treatments were included. A randomly ordered sample was screened until 200 eligible reports were found. Data on general characteristics, reporting characteristics, and time point alignment were extracted, and possible related biases, with a piloted form inspired by reporting guidelines and the target trial emulation framework.

Results

Of 462 reports of non-randomised studies identified, 262 studies were excluded (32% had no comparator and 25% did not account for confounding factors). To assess time point alignment and possible related biases, three study time points were considered: eligibility, treatment assignment, and start of follow-up. Of the 200 included reports, 70% had one possible bias, related to: inclusion of prevalent users in 24%, post-treatment eligibility criteria in 32%, immortal time periods in 42%, and classification of treatment in 23%. Reporting was incomplete, and only 2% reported all six of the key elements considered: eligibility criteria (87%), description of treatment (46%), deviations in treatment (27%), causal contrast (11%), primary outcomes (90%), and confounding factors (88%). Most studies used routinely collected data (67%), but only 7% reported using validation studies of the codes or algorithms applied to select the population. Only 7% of reports mentioned registration on a trial registry and 3% had an available protocol.

Conclusions

The findings of the study suggest that although access to real world evidence could be valuable, the robustness and transparency of non-randomised studies need to be improved.

CriteriaMapper: establishing the automatic identification of clinical trial cohorts from electronic health records by matching normalized eligibility criteria and patient clinical characteristics

The use of electronic health records (EHRs) holds the potential to enhance clinical trial activities. However, the identification of eligible patients within EHRs presents considerable challenges. We aimed to develop a CriteriaMapper system for phenotyping eligibility criteria, enabling the identification of patients from EHRs with clinical characteristics that match those criteria. We utilized clinical trial eligibility criteria and patient EHRs from the Mount Sinai Database. The CriteriaMapper system was developed to normalize the criteria using national standard terminologies and in-house databases, facilitating computability and queryability to bridge clinical trial criteria and EHRs. The system employed rule-based pattern recognition and manual annotation. Our system normalized 367 out of 640 unique eligibility criteria attributes, covering various medical conditions including non-small cell lung cancer, small cell lung cancer, prostate cancer, breast cancer, multiple myeloma, ulcerative colitis, Crohn's disease, non-alcoholic steatohepatitis, and sickle cell anemia. About 174 criteria were encoded with standard terminologies and 193 were normalized using the in-house reference tables. The agreement between automated and manual normalization was high (Cohen's Kappa = 0.82), and patient matching demonstrated a 0.94 F1 score. Our system has proven effective on EHRs from multiple institutions, showing broad applicability and promising improved clinical trial processes, leading to better patient selection, and enhanced clinical research outcomes.

A Comparative Effectiveness Study of Speech and Surgical Outcomes: Study Overview

AIMS

To provide an overview of the Cleft Outcomes Research NETwork (CORNET) and the CORNET Speech and Surgery study. The study is (1) comparing speech outcomes and fistula rate between two common palate repair techniques, straight-line closure with intra-velar veloplasty (IVVP) and Furlow Double-Opposing Z-palatoplasty (Furlow Z-plasty); (2) summarizing practice variation in the utilization of early intervention speech-language (EI-SL) services; and (3) exploring the association between EI-SL services and speech outcomes.

DESIGN

Prospective, longitudinal, observational, comparative effectiveness, multi-center.

SITES

Twenty sites across the United States.

PARTICIPANTS

One thousand two hundred forty-seven children with cleft palate with or without cleft lip (CP ± L). Children with submucous cleft palate or bilateral sensorineural severe to profound hearing loss were excluded from participation.

INTERVENTIONS

Straight-line closure with IVVP or Furlow Z-plasty based on each surgeon's standard clinical protocol.

MAIN OUTCOME MEASURE(S)

The primary study outcome is perceptual ratings of hypernasality judged from speech samples collected at 3 years of age. Secondary outcomes are fistula rate, measures of speech production, and quality of life. The statistical analyses will include generalized estimating equations with propensity score weighting to address potential confounders.

CURRENT PROGRESS

Recruitment was completed in February 2023; 80% of children have been retained to date. Five hundred sixty two children have completed their final 3-year speech assessment. Final study activities will end in early 2025.

CONCLUSIONS

This study addresses long-standing questions related to the effectiveness of the two most common palatoplasty approaches and describes CORNET which provides an infrastructure that will streamline future studies in all areas of cleft care.

What Explains Hop Growers' Fungicide Use Intensity and Management Costs in Response to Powdery Mildew?

Methods for causal inference from observational data are common in human disease epidemiology and social sciences but are used relatively little in plant pathology. We draw upon an extensive data set of the incidence of hop plants with powdery mildew (caused by Podosphaera macularis) collected from yards in Oregon from 2014 to 2017 and associated metadata on grower cultural practices, cultivar susceptibility to powdery mildew, and pesticide application records to understand variation in and causes of growers' fungicide use and associated costs. An instrumental causal forest model identified growers' spring pruning thoroughness, cultivar susceptibility to two of the dominant pathogenic races of P. macularis, network centrality of yards during May-June and June-July time transitions, and the initial strain of the fungus detected as important variables determining the number of pesticide active constituents applied by growers and the associated costs they incurred in response to powdery mildew. Exposure-response function models fit after covariate weighting indicated that both the number of pesticide active constituents applied and their associated costs scaled linearly with the seasonal mean incidence of plants with powdery mildew. Although the causes of pesticide use intensity are multifaceted, biological and production factors collectively influence the incidence of powdery mildew, which has a direct exposure-response relationship with the number of pesticide active constituents that growers apply and their costs. Our analyses point to several potential strategies for reducing pesticide use and costs for management of powdery mildew on hop. We also highlight the utility of these methods for causal inference in observational studies.

genRCT: a statistical analysis framework for generalizing RCT findings to real-world population

When evaluating the real-world treatment effect, the analysis based on randomized clinical trials (RCTs) often introduces generalizability bias due to the difference in risk factors between the trial participants and the real-world patient population. This problem of lack of generalizability associated with the RCT-only analysis can be addressed by leveraging observational studies with large sample sizes that are representative of the real-world population. A set of novel statistical methods, termed "genRCT", for improving the generalizability of the trial has been developed using calibration weighting, which enforces the covariates balance between the RCT and observational study. This paper aims to review statistical methods for generalizing the RCT findings by harnessing information from large observational studies that represent real-world patients. Specifically, we discuss the choices of data sources and variables to meet key theoretical assumptions and principles. We introduce and compare estimation methods for continuous, binary, and survival endpoints. We showcase the use of the R package genRCT through a case study that estimates the average treatment effect of adjuvant chemotherapy for the stage 1B non-small cell lung patients represented by a large cancer registry.

Transporting survival of an HIV clinical trial to the external target populations

Due to the heterogeneity of the randomized controlled trial (RCT) and external target populations, the estimated treatment effect from the RCT is not directly applicable to the target population. For example, the patient characteristics of the ACTG 175 HIV trial are significantly different from that of the three external target populations of interest: US early-stage HIV patients, Thailand HIV patients, and southern Ethiopia HIV patients. This paper considers several methods to transport the treatment effect from the ACTG 175 HIV trial to the target populations beyond the trial population. Most transport methods focus on continuous and binary outcomes; on the contrary, we derive and discuss several transport methods for survival outcomes: an outcome regression method based on a Cox proportional hazard (PH) model, an inverse probability weighting method based on the models for treatment assignment, sampling score, and censoring, and a doubly robust method that combines both methods, called the augmented calibration weighting (ACW) method. However, as the PH assumption was found to be incorrect for the ACTG 175 trial, the methods that depend on the PH assumption may lead to the biased quantification of the treatment effect. To account for the violation of the PH assumption, we extend the ACW method with the linear spline-based hazard regression model that does not require the PH assumption. Applying the aforementioned methods for transportability, we explore the effect of PH assumption, or the violation thereof, on transporting the survival results from the ACTG 175 trial to various external populations.

Machine Learning Methods to Estimate Individualized Treatment Effects for Use in Health Technology Assessment

BACKGROUND

Recent developments in causal inference and machine learning (ML) allow for the estimation of individualized treatment effects (ITEs), which reveal whether treatment effectiveness varies according to patients' observed covariates. ITEs can be used to stratify health policy decisions according to individual characteristics and potentially achieve greater population health. Little is known about the appropriateness of available ML methods for use in health technology assessment.

METHODS

In this scoping review, we evaluate ML methods available for estimating ITEs, aiming to help practitioners assess their suitability in health technology assessment. We present a taxonomy of ML approaches, categorized by key challenges in health technology assessment using observational data, including handling time-varying confounding and time-to event data and quantifying uncertainty.

RESULTS

We found a wide range of algorithms for simpler settings with baseline confounding and continuous or binary outcomes. Not many ML algorithms can handle time-varying or unobserved confounding, and at the time of writing, no ML algorithm was capable of estimating ITEs for time-to-event outcomes while accounting for time-varying confounding. Many of the ML algorithms that estimate ITEs in longitudinal settings do not formally quantify uncertainty around the point estimates.

LIMITATIONS

This scoping review may not cover all relevant ML methods and algorithms as they are continuously evolving.

CONCLUSIONS

Existing ML methods available for ITE estimation are limited in handling important challenges posed by observational data when used for cost-effectiveness analysis, such as time-to-event outcomes, time-varying and hidden confounding, or the need to estimate sampling uncertainty around the estimates.

IMPLICATIONS

ML methods are promising but need further development before they can be used to estimate ITEs for health technology assessments.

HIGHLIGHTS

Estimating individualized treatment effects (ITEs) using observational data and machine learning (ML) can support personalized treatment advice and help deliver more customized information on the effectiveness and cost-effectiveness of health technologies.ML methods for ITE estimation are mostly designed for handling confounding at baseline but not time-varying or unobserved confounding. The few models that account for time-varying confounding are designed for continuous or binary outcomes, not time-to-event outcomes.Not all ML methods for estimating ITEs can quantify the uncertainty of their predictions.Future work on developing ML that addresses the concerns summarized in this review is needed before these methods can be widely used in clinical and health technology assessment-like decision making.

Internet-Delivered Psychological Pain Management: A Prospective Cohort Study Examining Routine Care Delivery by a Specialist Regional Multidisciplinary Pain Service

Several clinical trials have demonstrated the effectiveness of internet-delivered psychological-based pain management programs (PMPs). However, to date, no large studies have reported the outcomes of PMPs when delivered by specialist multidisciplinary pain services in routine care. The present study reports (n = 653) the outcomes of an internet-delivered PMP provided as routine care by a specialist Australian regional pain service over a 6-year period. High levels of treatment commencement (85%) and completion (72%) were observed, with more than 80% of patients reporting they were satisfied with the intervention. Clinical improvements were observed from pretreatment to post-treatment (% change, 95% confidence intervals (CI)) in pain-related disability (8.8%; 4.5, 12.8), depression (28.4%; 23.0, 33.4), anxiety (21.9%; 14.6, 28.5), and pain intensity (7%; 3.5, 10.5), which were maintained to 3-month follow-up. At 3-month follow-up, 27% (23, 31), 46% (41, 51), 44% (39, 49), and 22% (19, 26) reported clinically meaningful (defined as ≥ 30%) improvements in pain-related disability, depression, anxiety, and pain intensity, respectively. These results were obtained with relatively little therapist time per patient (M = 30.0, (standard deviation) SD = 18.8) to deliver the intervention. The current findings highlight the potential of internet-delivered PMPs as part of the services provided by specialist pain services, particularly those servicing large geographical regions and for patients unable to travel to clinics for face-to-face care. PERSPECTIVE: This study reports the outcomes of the routine delivery of an internet-delivered psychological PMP by a specialist pain service. The findings highlight the potential of this model of care when provided by specialist pain services, particularly for patients not unable to attend and not requiring intensive face-to-face care.

A clinician's guide to performing a case series study

BACKGROUND

Whilst some guidance exists, the literature is relatively scarce on designing and reporting on case series studies for non-surgical techniques/interventions or interventions that may be considered outside the medical model. This commentary presents a set of thirteen design attributes and an adapted checklist for consideration by clinicians when considering a case series design focused on a non-surgical intervention.

Integrating randomized controlled trials and non-randomized studies of interventions to assess the effect of rare events: a Bayesian re-analysis of two meta-analyses

BACKGROUND

There is a growing trend to include non-randomised studies of interventions (NRSIs) in rare events meta-analyses of randomised controlled trials (RCTs) to complement the evidence from the latter. An important consideration when combining RCTs and NRSIs is how to address potential bias and down-weighting of NRSIs in the pooled estimates. The aim of this study is to explore the use of a power prior approach in a Bayesian framework for integrating RCTs and NRSIs to assess the effect of rare events.

METHODS

We proposed a method of specifying the down-weighting factor based on judgments of the relative magnitude (no information, and low, moderate, serious and critical risk of bias) of the overall risk of bias for each NRSI using the ROBINS-I tool. The methods were illustrated using two meta-analyses, with particular interest in the risk of diabetic ketoacidosis (DKA) in patients using sodium/glucose cotransporter-2 (SGLT-2) inhibitors compared with active comparators, and the association between low-dose methotrexate exposure and melanoma.

RESULTS

No significant results were observed for these two analyses when the data from RCTs only were pooled (risk of DKA: OR = 0.82, 95% confidence interval (CI): 0.25-2.69; risk of melanoma: OR = 1.94, 95%CI: 0.72-5.27). When RCTs and NRSIs were directly combined without distinction in the same meta-analysis, both meta-analyses showed significant results (risk of DKA: OR = 1.50, 95%CI: 1.11-2.03; risk of melanoma: OR = 1.16, 95%CI: 1.08-1.24). Using Bayesian analysis to account for NRSI bias, there was a 90% probability of an increased risk of DKA in users receiving SGLT-2 inhibitors and an 91% probability of an increased risk of melanoma in patients using low-dose methotrexate.

CONCLUSIONS

Our study showed that including NRSIs in a meta-analysis of RCTs for rare events could increase the certainty and comprehensiveness of the evidence. The estimates obtained from NRSIs are generally considered to be biased, and the possible influence of NRSIs on the certainty of the combined evidence needs to be carefully investigated.

Adverse Events During a 12-month Multi-Site and Dose-Response Aerobic Exercise Intervention

Purpose

This study aimed to assess the incidence of adverse events (AE) in older adults participating in a year-long exercise intervention, investigating potential dose-response relationships between exercise intensity and AE frequency, and identifying demographic factors associated with AE risk.

Methods

A total of 648 older adults were randomized into one of three exercise groups: low-intensity stretching and toning (S&T), 150 minutes of aerobic exercise per week (150Ex), or 225 minutes of aerobic exercise per week (225Ex). Adverse events were tracked during the intervention, with event rates calculated based on participant adherence and time in the study. Generalized linear models were employed to compare AE incidence across groups. Post hoc comparisons were used to calculate incidence rate ratios (IRRs) for AE between groups, adjusting for multiple comparisons.

Results

Overall, 306 AE were reported, with 44% related to the intervention. No significant dose-response relationship was observed for all-cause AE between groups. However, intervention-related AE were more frequent in the aerobic exercise groups. Participants in the 150Ex group had a 77% higher rate of intervention-related AE compared to the S&T group, and the 225Ex group had an 88% higher rate. Higher adherence was associated with fewer all-cause AE, and greater comorbid burden was associated with more AE.

Conclusions

While aerobic exercise increased the risk of intervention-related AE, the overall risk remained low. Higher adherence to the exercise regimen was associated with fewer AE. These findings suggest aerobic exercise is generally safe in older adults, with the benefits outweighing the risks.

Predictors of Satisfaction in Patients with Knee Osteoarthritis Treated with a Single Injection of Mannitol-Modified Crosslinked Hyaluronate Derivative

Background/Objectives: There is a gap between the very positive opinion of patients and doctors regarding knee viscosupplementation (VS) and the contrasting results of controlled studies. The objective of this study was to evaluate the overall satisfaction and predictors of satisfaction with VS in patients with knee osteoarthritis treated with VS. Methods: Post-hoc analysis of a cross-sectional study in patients with knee OA treated with one injection of a mannitol-modified cross-linked HA (HANOX-M-XL). The primary outcome was satisfaction, self-assessed semi-quantitatively by the patients. Demographics, radiological features, comorbidities, OA and comorbidities treatments, and lifestyle associated with satisfaction were studied in bivariate and multivariate analysis. Results: 89 patients (124 knees) were analyzed. A total of 88.7% were satisfied with the treatment. Satisfaction was correlated with duration of effectiveness (DoE) and negatively correlated with BMI. Satisfaction was higher in active versus sedentary patients, in tibiofemoral involvement, in Kellgren-Lawrence grade 1-3 versus 4, and in subjects not requiring intraarticular corticosteroid (IACS) concomitantly to VS. Satisfied subjects were older than dissatisfied ones. In multivariate analysis, older age, K-L grade < 4, absence of IACS, and longer DoE were associated with higher rates of satisfaction. Conclusions: We identified several predictive factors of patient satisfaction after VS of the knee. Alongside these objective factors, there are probably subjective factors linked to patient beliefs, fears, and expectations impacting satisfaction.

A Novel Digital Twin Strategy to Examine the Implications of Randomized Clinical Trials for Real-World Populations

Randomized clinical trials (RCTs) are essential to guide medical practice; however, their generalizability to a given population is often uncertain. We developed a statistically informed Generative Adversarial Network (GAN) model, RCT-Twin-GAN, that leverages relationships between covariates and outcomes and generates a digital twin of an RCT (RCT-Twin) conditioned on covariate distributions from a second patient population. We used RCT-Twin-GAN to reproduce treatment effect outcomes of the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial, which tested the same intervention but found different treatment effects. To demonstrate treatment effect estimates of each RCT conditioned on the other RCT's patient population, we evaluated the cardiovascular event-free survival of SPRINT digital twins conditioned on the ACCORD cohort and vice versa (ACCORD twins conditioned on SPRINT). The conditioned digital twins were balanced across intervention and control arms (mean absolute standardized mean difference (MASMD) of covariates between treatment arms 0.019 (SD 0.018), and the conditioned covariates of the SPRINT-Twin on ACCORD were more similar to ACCORD than SPRINT (MASMD 0.0082 SD 0.016 vs. 0.46 SD 0.20). Notably, across iterations, SPRINT conditioned ACCORD-Twin datasets reproduced the overall non-significant effect size seen in ACCORD (5-year cardiovascular outcome hazard ratio (95% confidence interval) of 0.88 (0.73-1.06) in ACCORD vs. median 0.87 (0.68-1.13) in the SPRINT conditioned ACCORD-Twin), while the ACCORD conditioned SPRINT-Twins reproduced the significant effect size seen in SPRINT (0.75 (0.64-0.89) vs. median 0.79 (0.72-0.86)) in the ACCORD conditioned SPRINT-Twin). Finally, we demonstrate the translation of this approach to real-world populations by conditioning the trials on an electronic health record population. Therefore, RCT-Twin-GAN simulates the direct translation of RCT-derived treatment effects across various patient populations.