Bias in Prospective Research and How to Avoid it

Study Design and Analysis in Hand Surgery Research: Tips for Success

Hand surgeons are constantly faced with evaluation of new evidence to identify best practices in clinical care. However, even the most rigorous study designs have limitations due to biases, generalizability, and other flaws. Here, we highlight seven common aspects of study design and analysis that should be considered by hand surgeons when interpreting findings. The evaluation of these practices can optimize the peer-review process and assess the value of evidence to be incorporated into clinical practice.

Evaluation of Alt-RAMEC With Facemask in Patients With Unilateral Cleft lip and Palate (UCLP) Using Cone Beam Computed Tomography (CBCT) and Finite Element Modeling-A Clinical Prospective Study

OBJECTIVE

Evaluate the effects of alternate rapid maxillary expansion and constriction (Alt-RAMEC) protocol on patients with unilateral cleft lip and palate (UCLP) along with maxillary protraction using cone beam computed tomography (CBCT) records and a finite element modeling (FEM) model.

MATERIALS AND METHODS

Twenty-five patients (aged 9-13 years) with UCLP having a GOSLON score 3 were selected for this prospective single-arm cohort study after obtaining necessary informed consent. A 9-week Alt-RAMEC protocol using a custom-made fan-shaped expansion screw was initiated, which was followed by 6-month facemask wear. Pre (T1) and posttreatment (T2) records including CBCT were taken and were evaluated for treatment changes in all 3 dimensions using paired t test. Additionally, a FEM model (ANSYS 15.0) using the Alt-RAMEC protocol was also analyzed for the displacement and stress on various craniofacial structures.

RESULTS

Significant forward movement of the maxilla along with clockwise rotation of mandible along with statistically significant increase in lower molar height and upper incisor proclination (P < .05) was observed. CBCT evaluation showed a statistical significant decrease in buccal alveolar bone thickness and increase in molar inclination (P < .05). Finite element modeling analysis highlighted that the maximum displacement occurred at the anterior region with stresses radiating till the anterior nasal spine, zygomatic arch, and sphenoid bone.

CONCLUSION

Alt- RAMEC protocol combined with facemask protraction can lead to significant maxillary advancement, with some transient decrease in buccal bone thickness noted thereby warranting long-term studies to further assess its effect on the dentofacial apparatus.

Effects of ACT Out! Social Issue Theater on Social-Emotional Competence and Bullying in Youth and Adolescents: Cluster Randomized Controlled Trial

BACKGROUND

Schools increasingly prioritize social-emotional competence and bullying and cyberbullying prevention, so the development of novel, low-cost, and high-yield programs addressing these topics is important. Further, rigorous assessment of interventions prior to widespread dissemination is crucial.

OBJECTIVE

This study assesses the effectiveness and implementation fidelity of the ACT Out! Social Issue Theater program, a 1-hour psychodramatic intervention by professional actors; it also measures students' receptiveness to the intervention.

METHODS

This study is a 2-arm cluster randomized control trial with 1:1 allocation that randomized either to the ACT Out! intervention or control (treatment as usual) at the classroom level (n=76 classrooms in 12 schools across 5 counties in Indiana, comprised of 1571 students at pretest in fourth, seventh, and tenth grades). The primary outcomes were self-reported social-emotional competence, bullying perpetration, and bullying victimization; the secondary outcomes were receptiveness to the intervention, implementation fidelity (independent observer observation), and prespecified subanalyses of social-emotional competence for seventh- and tenth-grade students. All outcomes were collected at baseline and 2-week posttest, with planned 3-months posttest data collection prevented due to the COVID-19 pandemic.

RESULTS

Intervention fidelity was uniformly excellent (>96% adherence), and students were highly receptive to the program. However, trial results did not support the hypothesis that the intervention would increase participants' social-emotional competence. The intervention's impact on bullying was complicated to interpret and included some evidence of small interaction effects (reduced cyberbullying victimization and increased physical bullying perpetration). Additionally, pooled within-group reductions were also observed and discussed but were not appropriate for causal attribution.

CONCLUSIONS

This study found no superiority for a 1-hour ACT Out! intervention compared to treatment as usual for social-emotional competence or offline bullying, but some evidence of a small effect for cyberbullying. On the basis of these results and the within-group effects, as a next step, we encourage research into whether the ACT Out! intervention may engender a bystander effect not amenable to randomization by classroom. Therefore, we recommend a larger trial of the ACT Out! intervention that focuses specifically on cyberbullying, measures bystander behavior, is randomized by school, and is controlled for extant bullying prevention efforts at each school.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04097496; https://clinicaltrials.gov/ct2/show/NCT04097496.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/17900.

Meta-analysis of Usefulness of Phrenic Nerve Stimulation in Central Sleep Apnea

Transvenous neurostimulation of the phrenic nerve (PNS) is a potentially improved and unique approach to the treatment of central sleep apnea (CSA). There have been multiple studies with limited individuals evaluating the efficacy of PNS. Our aim was to review and pool those studies to better understand whether phrenic nerve stimulation is efficacious in the treatment of CSA. The initial search on Pubmed retrieved a total of 97 articles and after screening all articles, only 5 could be included in our quantitative analysis. Pooling of data from 5 studies with a total of 204 patients demonstrated a reduction of mean apnea hypopnea index with PNS compared to controls by -26.7 events/hour with 95% confidence interval and P value of [CI (-31.99, -21.46), I² 85, p 0.00]. The mean difference in central apnea index was -22.47 [CI (-25.19, -19.76), I² 0, p 0.00]. The mean reduction in the oxygen desaturation index of 4% or more demonstrated a decrease in PNS group by -24.16 events/hour [(CI -26.20, -22.12), I² 0, p 0.00] compared with controls. PNS resulted in mean reduction in arousal index of -13.77 [CI (-16.15, -11.40), I² 0, p 0.00]. The mean change in percent of time spent in rapid eye movement sleep demonstrated a nonsignificant increase in PNS group by 1.01 % [CI (-5.67, 7.86), I²93, p 0.75]. In conclusion, PNS therapy for treating CSA demonstrated positive outcomes but larger randomized studies are needed to evaluate the safety and clinical outcomes.