Five good reasons to be disappointed with randomized trials

Evaluation of a Specialist Nurse-Led Post-Coronary Heart Disease Support Program: A Prospective Pre-Post Interventional Study

INTRODUCTION

The impact of multidisciplinary supervised cardiac rehabilitation programs on reducing the risk of having heart problems in the future is well documented. However, little is known about nurse-led post-coronary heart disease (post-CHD).

PURPOSE

Our aim was to evaluate the effectiveness of an educational and counseling-structured nurse-led post-CHD support program by assessing the prediction of psychological, behavioral and dietary variables in relation to adherence to a care plan in a single hospital in Athens (Greece).

METHOD

A prospective follow-up comparative approach in a single group of CHD patients was applied. The structured nurse-led program included eight topics (management of anxiety, physical activity, dietary habits, weight control, smoking cessation, alcohol moderation, family engagement and adherence to a care plan). Participants received tailored nursing interventions focused on psychological and behavioral needs and dietary habits by a CHD-specialized nurse based on patients' medical prescriptions and/or instructions. A modified clinical assessment questionnaire by the European Society of Cardiology was applied to identify pre-post clinical baseline measurements. A nurse-led post-coronary Heart Disease Support Program was evaluated by assessing the predictivity (effect) of specific interventions on adherence to a care plan by employing a logistic regression beta coefficient (Generalized Estimating Equations model).

RESULTS

The sample consisted of 275 patients (66.2% male), with a mean age of 68.5 ± 12.5 years old. CHD patients presented significantly lower anxiety rates (54.27 [1st m] vs. 49.63 [2nd m], p < 0.05). In addition, significant differences were observed between the first and the second measurements of total cholesterol (163.27 [1rst m] vs. 134.44 [2nd m], p < 0.001), BMI (obesity) (33.69 [1rst m] vs. 32.79 [2nd m], p < 0.001), smoking (42.18 [1rst m] vs. 22.55 [2nd m], p < 0.001) and adherence to a care plan (78.90 [1rst m] vs. 89.10 [2nd m], p < 0.001). A Generalized Estimating Equations model revealed that participants with higher levels of anxiety showed significantly lower adherence to a care plan (beta -0.10, p < 0.001) and those with family history of CHD (beta -0.71, p = 0.04) in comparison to those with no CHD history. No significant differences were observed in the predictive variables of smoking (beta 0.08, p = 0.69), alcohol consumption (beta 0.09, p = 0.79) and family engagement (beta -0.11, p = 069) with respect to adherence to a care plan, even after adjusting for age, sex and history of CHD.

CONCLUSION

Our findings indicate that the nurse-led post-CHD support program was found to be partially feasible and effective in our single-group study, emphasizing the need for effective training and retention strategies to enhance the specialization of nurses providing post-CHD care and support.

Complications of preseptal versus retroseptal transconjunctival approach for isolated orbital floor fracture repair: A double-blind, non-inferiority, randomized, split-face controlled trial

INTRODUCTION

Effective surgical access to the orbital floor facilitates surgery and mitigates postoperative complications (PC). The aim of this study was to compare PC between the preseptal and retroseptal transconjunctival approaches (PS-TCA/RS-TCA) for isolated orbital floor fracture (OFF).

MATERIALS AND METHODS

Using a double-blind, non-inferiority, randomized, split-face study design, patients aged ≥ 18 years with bilateral isolated OFF were enrolled. A sample size of 177 eyes per group was determined through power analysis. The primary predictor variable was the surgical approach, and the main outcome was the PC rate at month 6. Statistical analyses were computed with a significance level at 0.05 and the non-inferiority margin at a relative risk (RR) of 0.045.

RESULTS

The final sample included 193 patients (23.3 % female; age, 42.8 ± 18.1 years). Both TCA variants exhibited comparable PC rates (5.2 % for PS-TCA vs. 7.3 % for RS-TCA; P = 0.53; absolute risk, +2.07 % [95 % CI, -2.74 % to 6.89 %]; RR, 1.4 [95 % CI, 0.64 to 3.07]). Approximately one in every 49 patients experiencing PC with RS-TCA (number needed to harm, 48.3).

CONCLUSIONS

Both TCA methods can be used without different PC rates at 6 months postoperatively. Future research should focus on TCA in combination with other surgical approaches for multiple orbital wall reconstruction.

Navigating foster care: how parental drug use and caregiver attitudes shape children's mentalization processes-an exploratory longitudinal follow-up study: study protocol

Background

The current research concept of mentalization is used in the study to clearly identify affective and cognitive abilities of the caregiver-child dyad with the aim of compensating deficits on both sides with psychological-psychotherapeutic strategies.

Methods

The objective of this explorative, longitudinal intervention study is to provide an in-depth understanding of the psycho-social background of 30 children aged 6-12 years living in institutional or family-centered foster care. Data will be collected at three time points: before, after and 12 months after participating in the newly developed group intervention, which intends to address the particular needs of children of drug abusing parents living in foster care in the latency period. The study is conducted at the Faculty of Psychology of the University of Vienna in collaboration with the Association "Dialogue" (Verein Dialog). The treatment duration spans 5 months, during which two specifically trained psychotherapists conduct 10 group sessions for children and three group sessions for foster caregivers. All statistical analyses will consider the type of data available. Therefore, the primary outcome of the study will be assessed via the Friedman test due to the ordinal dependent variable as it is the non-parametric alternative to the one-way ANOVA for repeated measures. In addition, the Mann-Whitney U test is used to compare differences between two independent groups (children living in institutional foster care vs. family foster care). To assess potential correlations regarding the child and caregivers' capacity to mentalize, Spearman correlations (ρ) are conducted. To examine the secondary outcome, apart from the methods previously outlined, we will also utilize qualitative thematic analysis.

Discussion

The present study uses the current research concept of mentalization to identify affective and cognitive abilities of the caregiver-child dyad with the aim of compensating deficits on both sides with psychological-psychotherapeutic strategies. There are some limitations of the study to mention: the small sample size does not allow to generalize the results. Due to the lack of a comparison group, a randomized control study (RCT) was not conducted. The authors are aware of these limitations. However, the studies' findings, will help to deduce research questions for further studies.

Propensity-score matched analysis of patent foramen ovale closure in real-world study cohort with cryptogenic ischemic stroke

INTRODUCTION

Patent foramen ovale (PFO) occurs in 25% of the general population and in 40% of cryptogenic ischemic stroke patients. Recent trials support PFO closure in selected patients with cryptogenic stroke. We examined the outcomes of transcatheter PFO closure in a real-world study cohort with cryptogenic stroke.

METHODS

Consecutive ischemic stroke patients who were classified as cryptogenic on the TOAST aetiology and diagnosed with a PFO were included. All patients underwent either transcatheter PFO closure or medical therapy. A 2:1 propensity score matching by sex and Risk-of-Paradoxical-Embolism (RoPE) score was performed. Multivariable regression models adjusted for sex and RoPE score.

RESULTS

Our cohort comprised 232 patients with mean age 44.3 years (SD 10.8) and median follow-up 1486.5 days. 33.2% were female. PFO closure (n=84) and medical therapy (n=148) groups were well-matched with <10% mean-difference in sex and RoPE score. Two patients in the treated group (2.4%) and seven in the control group (4.7%) had a recurrent ischemic stroke event. Multivariable Cox regression demonstrated a hazard-ratio of 0.26 (95%CI 0.03-2.13, P=0.21) for PFO closure compared to control. The incidence of atrial fibrillation (AF) detected post-PFO closure was similar between the treated and control (1.19% vs 1.35%, multivariable logistic regression odds-ratio 0.90, 95%CI 0.04-9.81, P=0.94). There were no major periprocedural complications documented. The difference in restricted mean survival-time free from stroke at two years between treated and control was 26.2 days (95%CI 5.52-46.85, P=0.013).

CONCLUSIONS

In this Asian cohort, we report a low incidence of ischemic stroke recurrence and new-onset AF in patients who underwent PFO closure. When compared to the medical therapy group, there was no significant difference in the incidence of stroke recurrence and new-onset AF. Further studies involving larger real-world cohorts are warranted to identify patients who are more likely to benefit from PFO closure.

Decoding the Misinformation-Legislation Pipeline: an analysis of Florida Medicaid and the current state of transgender healthcare

Background

The state of evidence-based transgender healthcare in the United States has been put at risk by the spread of misinformation harmful to transgender people. Health science librarians can alleviate the spread of misinformation by identifying and analyzing its flow through systems that affect access to healthcare.

Discussion

The author developed the theory of the Misinformation - Legislation Pipeline by studying the flow of anti-transgender misinformation from online echo chambers through a peer-reviewed article and into policy enacted to ban medical treatments for transgender people in the state of Florida. The analysis is precluded with a literature review of currently accepted best practices in transgender healthcare, after which, the author analyzes the key report leveraged by Florida's Department of Health in its ban. A critical analysis of the report is followed by a secondary analysis of the key peer-reviewed article upon which the Florida Medicaid authors relied to make the decision. The paper culminates with a summation of the trajectory of anti-transgender misinformation.

Conclusion

Misinformation plays a key role in producing legislation harmful to transgender people. Health science librarians have a role to play in identifying misinformation as it flows through the Misinformation - Legislation Pipeline and enacting key practices to identify, analyze, and oppose the spread of harmful misinformation.

Vitamin D and Periodontal Health: A Systematic Review

The role of vitamin D in maintaining gum well-being is crucial. However, scientific research reported that the connotations of cholecalciferol and periodontal health have been divested in the present literature. However, there is enormous heterogeneity in the data available. The current review aims to systematically review and appraise the available literature investigating the role of vitamin D in maintaining periodontal health. Studies included randomized controlled trials and clinical trials following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and cohort studies reporting associations between vitamin D and oral health in systemically healthy patients. Databases such as PubMed, Google Scholar, Scopus, Embase, and other sources, including hand search, were searched until May 2023 using together-equipped search sequences. Altogether, scientific articles that conform to the inclusion principles underwent a thorough eminence evaluation. All papers meeting inclusion criteria were subject to quality assessment, and the method used to assess the risk of bias was the Cochrane risk of bias tool. The search identified 1883 papers, among which 1435 were excluded after title evaluation. After abstract and title screening, 455 were excluded, and six full texts were assessed. After full-text evaluation, two articles were excluded, and only four were included. The data shows vitamin D's association with oral health maintenance. Along with its action on bone metabolism, it has extended function, which provides for its action as an anti-inflammatory agent and production of anti-microbial peptides, which help maintain oral health. Although the literature available is immense, there is enormous heterogenicity in the papers conducted to appraise the association between vitamin D and oral health. This systematic review has filtered all the data to review a few essential aspects of the role of vitamin D in maintaining oral physiology. Vitamin D has a linear relationship with periodontal health; however, the evidence is insufficient, and further studies must be done.

Plain Language vs Standard Format for Youth Understanding of COVID-19 Recommendations: A Randomized Clinical Trial

Importance

To ensure that youths can make informed decisions about their health, it is important that health recommendations be presented for understanding by youths.

Objective

To compare understanding, accessibility, usability, satisfaction, intention to implement, and preference of youths provided with a digital plain language recommendation (PLR) format vs the original standard language version (SLV) of a health recommendation.

Design, Setting, and Participants

This pragmatic, allocation-concealed, blinded, superiority randomized clinical trial included individuals from any country who were 15 to 24 years of age, had internet access, and could read and understand English. The trial was conducted from May 27 to July 6, 2022, and included a qualitative component.

Interventions

An online platform was used to randomize youths in a 1:1 ratio to an optimized digital PLR or SLV format of 1 of 2 health recommendations related to the COVID-19 vaccine; youth-friendly PLRs were developed in collaboration with youth partners and advisors.

Main Outcomes and Measures

The primary outcome was understanding, measured as the proportion of correct responses to 7 comprehension questions. Secondary outcomes were accessibility, usability, satisfaction, preference, and intended behavior. After completion of the survey, participants indicated their interest in completing a 1-on-1 semistructured interview to reflect on their preferred digital format (PLR or SLV) and their outcome assessment survey response.

Results

Of the 268 participants included in the final analysis, 137 were in the PLR group (48.4% female) and 131 were in the SLV group (53.4% female). Most participants (233 [86.9%]) were from North and South America. No significant difference was found in understanding scores between the PLR and SLV groups (mean difference, 5.2%; 95% CI, -1.2% to 11.6%; P = .11). Participants found the PLR to be more accessible and usable (mean difference, 0.34; 95% CI, 0.05-0.63) and satisfying (mean difference, 0.39; 95% CI, 0.06-0.73) and had a stronger preference toward the PLR (mean difference, 4.8; 95% CI, 4.5-5.1 [4.0 indicated a neutral response]) compared with the SLV. No significant difference was found in intended behavior (mean difference, 0.22 (95% CI, -0.20 to 0.74). Interviewees (n = 14) agreed that the PLR was easier to understand and generated constructive feedback to further improve the digital PLR.

Conclusions and Relevance

In this randomized clinical trial, compared with the SLV, the PLR did not produce statistically significant findings in terms of understanding scores. Youths ranked it higher in terms of accessibility, usability, and satisfaction, suggesting that the PLR may be preferred for communicating health recommendations to youths. The interviews provided suggestions for further improving PLR formats.

Trial Registration

ClinicalTrials.gov Identifier: NCT05358990.

Using Randomized Controlled Trials in the Sports Medicine and Performance Environment: Is It Time to Reconsider and Think Outside the Methodological Box?

SYNOPSIS: Randomized controlled trials (RCTs) are ubiquitous in medicine and have facilitated great strides in clinical care. However, when applied in sport, RCTs have limitations that hinder implementing effective interventions in the real-world clinical setting. Pragmatic clinical trials offer some solutions. Yet due to the competitive, high-pressure nature of sport at the individual, team, and governing body level, RCTs are likely infeasible in certain sport settings. The small number of athletes at the elite team level, along with the potential financial consequences of randomizing at the individual athlete and team level, also restricts study power and feasibility, limiting conclusions. Consequently, researchers may need to "think outside the box" and consider other research methodology, to help improve athlete care. In this Viewpoint, we detail alternative study designs that can help solve real-world problems in sports medicine and performance, while maintaining robust research standards and accounting for the challenges that RCTs pose. We also provide practical examples of alternative designs. J Orthop Sports Phys Ther 2023;53(6):1-4. Epub: 18 April 2023. doi:10.2519/jospt.2023.11824.

A scoping review of family-centered interventions in dementia care

Families of persons living with dementia provide varying levels and forms of support to their loved ones and experience changes in familial dynamics, roles, and responsibilities over time. Family-centered care can enable their successful adaptation and participation in meaningful occupations. This scoping review aimed to explore available familycentered interventions for persons living with dementia, with a focus on occupational therapy. Three databases were searched and 31 eligible studies were found. Thirteen family-centered interventions were identified that were mostly multicomponent in nature, of which three involved occupational therapy. These interventions were investigated using a range of study designs and addressed outcomes related to the person with dementia, primary caregiver, and extended social network. With respect to study context, most interventions were developed in the United States and other Western countries with a limited number located in other contexts. The review findings underline the need for developing more family-centered interventions within occupational therapy, particularly for different contexts and cultures, and for translating available interventions to practice.

Shoulder Range of Motion Measurements and Baseball Elbow Injuries: Ambiguity in Scientific Models, Approach, and Execution is Hurting Overhead Athlete Health

Elbow injuries are a significant and increasing issue in baseball. Elbow injuries account for 16% of all injuries sustained at the professional level and collegiate level. Because of the continued rise in injury rates, loss of performance value, and medical burden, sports medicine clinicians have attempted to research the causes underlying this injury epidemic in an attempt to help mitigate baseball elbow injuries. Shoulder range of motion (ROM) is the most researched clinical metric related to elbow injuries in baseball and has the greatest consensus as a viable prognostic factor specifically for medial elbow injury. Shoulder ROM is easy to measure, can be modified through stretching and manual therapy interventions, and can be easily assessed during preseason screening throughout all baseball levels. Despite a large number of studies and the widespread use of shoulder ROM in injury risk screening, current findings are unclear as to whether there is a true cause-effect relation with baseball elbow injuries. We argue that the conflicting findings revolving around the value of shoulder ROM measurements associated with baseball elbow injuries are the result of 4 gaps in the research approaches implemented to date: ambiguous research questions, mixed study populations, statistical models used, and shoulder ROM methodology. Specifically, there is a mismatch of methods, statistical models, and conclusions such as (1) investigating the association (i.e., correlation) between shoulder ROM measurements and injury and (2) investigating the cause-effect relation of shoulder ROM to baseball injuries. The purpose of this article is to detail the required scientific steps to evaluate whether preseason shoulder ROM is a potential causal factor for pitching elbow injury. We also provide recommendations to allow for future causal inferences to be made between shoulder ROM and elbow injury. This information will ultimately assist in informing clinical models of care and decision making for baseball throwers.

Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review

BACKGROUND

Millions of children and adolescents are exposed to wars, affecting their psychological well-being. This review focuses on psychosocial interventions in low and middle-income countries (LMICs) in the Middle East, where mental health services are limited.

AIMS

Our primary aim was to evaluate the effectiveness of trial-assessed psychosocial interventions in reducing post-traumatic stress disorder (PTSD) symptoms in children and adolescents aged ≤18 years who were exposed to war in LMICs in the Middle East. Changes in other psychological conditions and symptoms were evaluated where reported.

METHOD

PubMed, Cochrane Library and Ovid were searched without year restriction, in December 2021. Previous review reference lists were also checked. Only studies published in English were included. Each study was evaluated for risk of bias and results are presented as a narrative synthesis.

RESULTS

Three group-based interventions were identified and evaluated across six studies: 'Teaching Recovery Techniques', 'Writing for Recovery' and 'Advancing Adolescents'. Two studies took place in post-war settings, and four in a context of ongoing conflict. Positive experiences and improved social skills were indicated following most interventions, but Teaching Recovery Techniques was the only programme associated with a statistically significant reduction in PTSD score. Differences in follow-up interval limited comparability of outcomes.

CONCLUSIONS

This review highlights a paucity of evidence for effective treatment options for children and adolescents affected by war from LMICs in the Middle East. Promising indications of reductions in PTSD symptoms, specifically from Teaching Recovery Techniques, require further rigorous evaluation and long-term follow-up.

Protocol for a multicenter, randomised controlled trial of surgeon-directed home therapy vs. outpatient rehabilitation by physical therapists for reverse total shoulder arthroplasty: the SHORT trial

Background

Reverse total shoulder arthroplasty (RTSA) has emerged as a successful surgery with expanding indications. Outcomes may be influenced by post-operative rehabilitation; however, there is a dearth of research regarding optimal rehabilitation strategy following RTSA. The primary purpose of this study is to compare patient reported and clinical outcomes after RTSA in two groups: in one group rehabilitation is directed by formal, outpatient clinic-based physical therapists (PT group) as compared to a home therapy group, in which patients are instructed in their rehabilitative exercises by surgeons at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care and quality of life between the two groups.

Methods

This randomised controlled trial has commenced at seven sites across the United States. Data is being collected on 200 subjects by clinical research assistants pre-operatively and post-operatively at 2, 6, and 12 weeks, 6 months, 1 and 2 year visits. The following variables are being assessed: American Shoulder and Elbow Surgeons (ASES), pain level using the numeric pain scale, the Single Assessment Numeric Evaluation (SANE) score, and shoulder active and passive range of motion for analysis of the primary aim. Chi square and t-tests will be used to measure differences in baseline characteristics of both groups. Repeated measures linear mixed effects modeling for measurement of differences will be used for outcomes associated with ASES and SANE and scores, and range of motion measures. Secondary aims will be analyzed for comparison of complications, cost, and quality of life assessment scores using data obtained from the PROMIS 29 v. 2, questionnaires administered at standard of care post-operative visits, and the electronic health record. Subjects will be allowed to crossover between the PT and HT groups, and analysis will include both intention-to-treat including patients who crossed over, and a second with cross-over patients removed, truncated to the time they crossed over.

Discussion

RTSA is being performed with increasing frequency, and the optimal rehabilitation strategy is unclear. This study will help clarify the role of formal physical therapy with particular consideration to outcomes, cost, and complications. In addition, this study will evaluate a proposed rehabilitation strategy.

Trial registration

This study is registered as NCT03719859 at ClincialTrials.gov.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00121-2.

Sample size, study length, and inadequate controls were the most common self-acknowledged limitations in manual therapy trials: A methodological review

OBJECTIVES

The aim of this study was to quantify and analyze the presence and type of self-acknowledged limitations (SALs) in a sample of manual therapy (MT) randomized controlled trials.

STUDY DESIGN AND SETTING

We randomly selected 120 MT trials. We extracted data related to SALs from the original reports and classified them into 12 categories. After data extraction, specific limitations within each category were identified. A descriptive analysis was performed using frequencies and percentages for qualitative variables.

RESULTS

The number of SALs per trial article ranged from 0 to 8, and more than two-thirds of trials acknowledged at least two different limitations. Despite its small proportion, 9% of trials did not report SALs. The most common limitation declared, in almost half of our sample, related to sample size (47.5%) followed by limitations related to study length and follow-up (33.3%) and inadequate controls (32.5%).

CONCLUSION

Our results indicate that at least two different limitations are consistently acknowledged in MT trial reports, the most common being those related to sample size, study length, follow-up, and inadequate controls. Analysis of the reasons behind the SALs gives some insights about the main difficulties in conducting research in this field and may help develop strategies to improve future research.

"I'm in a very good frame of mind": a qualitative exploration of the experience of standing frame use in people with progressive multiple sclerosis

OBJECTIVES

The study aim was to explore the experiences of people with progressive multiple sclerosis (MS) and their standing assistants during their participation in Standing Up in Multiple Sclerosis, a randomised controlled trial (RCT) of a home-based, self-managed standing frame programme.

DESIGN

A qualitative approach, using audio diary methodology was used to collect data contemporaneously. Diary data were transcribed verbatim and analysed using thematic analysis.

SETTING

Participants were recruited from eight healthcare organisations in two regions of the UK. The intervention was home-based.

PARTICIPANTS

As part of the RCT, 140 participants were randomly allocated to either usual care or usual care plus a standing frame programme. Using a sampling matrix 12 people with progressive MS (6 female, aged 35-71 years, Expanded Disability Status Scale 6.5-8.0) and 8 standing assistants (4 female) kept audio diaries of their experiences.

INTERVENTION

The standing frame programme involved two face-to-face home-based physiotherapy sessions to set up the standing frame programme, supplemented by educational material designed to optimise self-efficacy. Participants were encouraged to stand for at least 30 min, three times a week for the 36-week study period.

RESULTS

Four main themes were identified: "Feeling like the old me"; 'Noticing a difference'; "I want to do it right" and "You have a good day, you have a bad day".

CONCLUSIONS

Supported standing helped people with progressive MS feel more like their old selves and provided a sense of normality and enjoyment. People noticed improvements in physical and psychological symptoms, which were often associated with increased participation in activities they valued. Provision of support from a physiotherapist and recognition of the variable nature of the condition were highlighted as factors to consider when establishing a standing programme.

TRIAL REGISTRATION NUMBER

ISRCTN69614598.