N-of-1 trials: innovative methods to evaluate complementary and alternative medicines in pediatric cancer

Evaluating the Comparative Effectiveness of Two Diets in Pediatric Inflammatory Bowel Disease: A Study Protocol for a Series of N-of-1 Trials

Inflammatory bowel disease (IBD) affects 3 million children and adults in the US. Treatment involves medications with considerable risk profiles. Dietary modification, such as the specific carbohydrate diet (SCD), may be helpful in treating IBD, but there is insufficient evidence of its effectiveness. N-of-1 trials are ideal for addressing this important research question. The Personalized Research on Diet in Ulcerative Colitis and Crohn’s Disease (PRODUCE) study employs a series of 50 individual N-of-1 trials that compare the SCD to a modified SCD. Treatment periods are assigned in blocks of two, with each patient completing two balanced treatment blocks. Patients are randomized to start with the SCD or modified SCD and alternate between conditions for four eight-week periods. A mobile app guides collecting and viewing data, transitioning diets, and reviewing personal results. Primary outcomes include patient reported outcomes (PROs) of stool frequency, stool consistency, pain interference, and gastrointestinal (GI) symptom severity. We examine changes in inflammation via fecal calprotectin. Participants will receive a personalized answer regarding comparative effectiveness between the SCD and a less restrictive diet option (modified SCD), as well as compared to their baseline diet. We will aggregate the results of completed N-of-1 trials across patients to estimate population level comparative effectiveness of these treatments and the effectiveness of each diet.

Research methods in complementary and alternative medicine: an integrative review

The scientific literature presents a modest amount of evidence in the use of complementary and alternative medicine (CAM). On the other hand, in practice, relevant results are common. The debates among CAM practitioners about the quality and execution of scientific research are important. Therefore, the aim of this review is to gather, synthesize and describe the differentiated methodological models that encompass the complexity of therapeutic interventions. The process of bringing evidence-based medicine into clinical practice in CAM is essential for the growth and strengthening of complementary medicines worldwide.

Traditional and complementary medicine used with curative intent in childhood cancer: A systematic review

Traditional and complementary medicine (T&CM) strategies are widely utilized in pediatric oncology, with many families reporting T&CM use with the intention to cure cancer. Study of T&CM agents presents many challenges, as a heterogeneous group of agents and techniques are used for a variety of different purpose in many different oncologic conditions. We present a systematic review of the literature examining published reports in which T&CM agents are used with an intention of cure. Twenty-two reports were identified, with most reports being of poor quality. Novel paradigms are likely needed to further investigate T&CM agents.

Key issues in clinical and epidemiological research in complementary and alternative medicine--a systematic literature review

BACKGROUND

In the last 2 decades there has been a large increase in publications on complementary and alternative medicine (CAM). However, CAM research methodology was heterogeneous and often of low quality. The aim of this systematic review was to investigate scientific publications with regards to general issues, concepts and strategies. We also looked at research priorities and methods employed to evaluate the clinical and epidemiological research of CAM in the past to identify the basis for consensus-based research strategies.

METHODS

We performed a systematic literature search for papers published between 1990 and 2010 in 7 electronic databases (Medline, Web of Science, PsychArticles, PsycInfo, CINAHL, EMBASE and Cochrane Library) on December 16 and 17, 2010. In addition, experts were asked to nominate relevant papers. Inclusion criteria were publications dealing with research methodology, priorities or complexities in the scientific evaluation of CAM. All references were assessed in a multistage process to identify relevant papers.

RESULTS

From the 3,279 references derived from the search and 98 references contributed by CAM experts, 170 papers fulfilled the criteria and were included in the analysis. The following key issues were identified: difficulties in past CAM research (e.g., randomisation, blinding), utility of quantitative and qualitative research methods in CAM, priority setting in CAM research and specific issues regarding various CAM modalities.

CONCLUSIONS

Most authors vote for the use of commonly accepted research methods to evaluate CAM. There was broad consensus that a mixed methods approach is the most suitable for gathering conclusive knowledge about CAM.

A Novel N of 1 Trial Design and Proposed Utility in Complementary and Alternative Medicine Research

An N of 1 trial is a multiple crossover study in a single participant. N of 1trials can combine the benefits of individualized patient practice and evidence-based medicine and are amenable to complementary and alternative medicine practice and research. This article will review the basic structure of N of 1trials, discuss how they are commonly used, and review their limitations and statistical considerations. The authors also propose a novel use of the N of 1 trial in the form of mixed-methodology add-on N of 1 trials targeted to a parent trial’s responders. This design can help uncover evidence of subgroup effects in small trials, address issues surrounding the small study effect, and explore the role of interparticipant variability and random chance in the parent trial.

How do we evaluate outcome in an integrative oncology program?

Integrative oncology focuses on the roles of complementary therapies to increase the effectiveness of conventional cancer treatment programs by improving defined outcomes such as symptom control, quality of life, rehabilitation, and prevention of recurrence. Implementation of integrative oncology programs should be based on the best evidence and must continually be evaluated to ensure quality, optimization of techniques, collection of new data, and cost-effectiveness. Useful domains that can be evaluated include symptom control, adherence to treatment protocols, quality of life, individual outcomes, prevention, rehabilitation, potential advantages of a whole-systems health approach, and economics of health services.

Challenges in the design and conduct of therapeutic trials in channel disorders

Neurologic channelopathies are rare, inherited paroxysmal disorders of muscle (e.g., the periodic paralyses and nondystrophic myotonias) and brain (e.g., episodic ataxias, idiopathic epilepsies, and familial hemiplegic migraine). Mutation is necessary but not sufficient for phenotypic expression and there are no simple phenotype-genotype relationships. Attacks may be spontaneous or triggered, with affected individuals often asymptomatic and neurologically normal between attacks. Performance of daily activities may be affected by the unpredictable nature; often late-onset degenerative changes cause permanent disability; for example, muscle atrophy and fixed weakness in periodic paralysis and cerebellar atrophy and progressive ataxia in the episodic ataxias. Currently, the natural history of these disorders is being defined. Clearly, the established methodologies for randomized controlled clinical trials are not feasible for rare diseases and innovative trial design is essential. There is a requirement for clinically relevant outcome measures for episodic disorders. Increasing our knowledge of the pathophysiology will help in targeting and designing rational therapeutic approaches. We will use the current understanding of the neurological channelopathies to illustrate some of the opportunities, challenges, and strategies in bringing safe and effective treatments to patients. There are reasons for optimism that new partnerships between clinical investigators, government, patient advocacy groups, and industry will prevent symptoms and progression of the neurological channelopathies.

Towards a Model for Planning Clinical Research in Oriental Medicine

BACKGROUND

Oriental medicine (OM) is widely practiced internationally and embraces many schools of thought. Western medical research is currently struggling to understand OM in purely biomedical terms, with limited success.

OBJECTIVE

We propose a research model for applying Western research methodologies to OM in a way that respects its theory and modes of clinical application. This would facilitate systematic investigations of OM's specific assumptions and make explicit the way OM studies could build on each other.

METHODS

To develop this model, the authors extracted key assumptions of Western research methodology germane to clinical research, put them in a developmentally logical sequence, and related them to the diagnostic and clinical processes of OM.

RESULTS

The model categorizes studies into seven levels. Foundation studies (level one) establish the conceptual basis for OM research by establishing the internal validity of its basic "truth statements." Measurement studies (level two) determine how OM identifies and measures diagnostic indicators, treatment outcomes, and other basic aspects of health. Group studies (level three) describe populations in ways meaningful to their health. Pattern/diagnosis studies (level four) identify and define OM patterns of disharmony. Treatment technique studies (level five) describe particular techniques or principles of treatment, their indications, and rationale. Treatment effectiveness studies (level six) evaluate techniques of treatment, often by comparing the results of one technique with those of another in similar patients. Systematic reviews (level seven) draw together studies on the same topic to see if conclusions are thereby strengthened.

CONCLUSION

The levels can be used to establish relationships between already published studies, determine if sufficient background research has been done to enable a study idea to be carried out, and generate ideas for future studies.