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Papoutsi E, Kremmydas P, Tsolaki V, Kyriakoudi A, Routsi C, Kotanidou A, Siempos II. Racial and ethnic minority participants in clinical trials of acute respiratory distress syndrome. Intensive Care Med 2023; 49:1479-1488. [PMID: 37847403 PMCID: PMC10709247 DOI: 10.1007/s00134-023-07238-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE There is growing interest in improving the inclusiveness of racial and ethnic minority participants in trials of acute respiratory distress syndrome (ARDS). With our study we aimed to examine temporal trends of representation and mortality of racial and ethnic minority participants in randomized controlled trials of ARDS. METHODS We performed a secondary analysis of eight ARDS Network and PETAL Network therapeutic clinical trials, published between 2000 and 2019. We classified race/ethnicity into "White", "Black", "Hispanic", or "Other" (including Asian, American Indian or Alaskan Native, Native Hawaiian, or other Pacific Islander participants). RESULTS Of 5375 participants with ARDS, 1634 (30.4%) were Black, Hispanic, or Other race participants. Representation of racial and ethnic minority participants in trials did not change significantly over time (p = 0.257). However, among participants with moderate to severe ARDS (i.e., partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 150), the difference in mortality between racial and ethnic minority participants and White participants decreased over time. In the five most recent trials, including 2923 participants with ARDS, there were no statistically significant differences in mortality between racial/ethnic groups, even after adjusting for potential confounders. In these five most recent trials, mortality was 31% for White, 31.9% for Black, 30.3% for Hispanic, and 37.1% for Other race participants (p = 0.633). CONCLUSION Representation of racial and ethnic minority participants in ARDS trials from North America, published between 2000 and 2019, did not change over time. Black and Hispanic participants with ARDS may have similar mortality as White participants within trials.
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Affiliation(s)
- Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Panagiotis Kremmydas
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, University of Thessaly Faculty of Medicine, Larissa, Greece
| | - Anna Kyriakoudi
- First Department of Respiratory Medicine, Thoracic Diseases General Hospital Sotiria, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Routsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
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Kho ME, Reid J, Molloy AJ, Herridge MS, Seely AJ, Rudkowski JC, Buckingham L, Heels-Ansdell D, Karachi T, Fox-Robichaud A, Ball IM, Burns KEA, Pellizzari JR, Farley C, Berney S, Pastva AM, Rochwerg B, D'Aragon F, Lamontagne F, Duan EH, Tsang JLY, Archambault P, English SW, Muscedere J, Serri K, Tarride JE, Mehta S, Verceles AC, Reeve B, O'Grady H, Kelly L, Strong G, Hurd AH, Thabane L, Cook DJ. Critical Care C ycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients. BMJ Open 2023; 13:e075685. [PMID: 37355270 PMCID: PMC10314658 DOI: 10.1136/bmjopen-2023-075685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults. METHODS AND ANALYSIS We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups. ETHICS AND DISSEMINATION Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).
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Affiliation(s)
- Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Julie Reid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alexander J Molloy
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- University Health Network, Toronto General Research Institute, Toronto, Ontario, Canada
| | - Andrew J Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jill C Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lisa Buckingham
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Ian M Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Karen E A Burns
- Li Sha King Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, Unity Health Toronto, Toronto, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Farley
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sue Berney
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amy M Pastva
- Departments of Medicine and Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Bram Rochwerg
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke Faculte de medecine et des sciences de la sante, Sherbrooke, Quebec, Canada
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Francois Lamontagne
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
- Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Erick H Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Patrick Archambault
- Anesthesiology and Intensive Care, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
- Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
| | - Shane W English
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Karim Serri
- Critical Care Division, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Québec, Canada
| | - Jean-Eric Tarride
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Toronto, Ontario, Canada
| | - Avelino C Verceles
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brenda Reeve
- Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | - Heather O'Grady
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Laurel Kelly
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Geoff Strong
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Abby H Hurd
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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Wick KD, Aggarwal NR, Curley MAQ, Fowler AA, Jaber S, Kostrubiec M, Lassau N, Laterre PF, Lebreton G, Levitt JE, Mebazaa A, Rubin E, Sinha P, Ware LB, Matthay MA. Opportunities for improved clinical trial designs in acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:916-924. [PMID: 36057279 DOI: 10.1016/s2213-2600(22)00294-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/02/2022] [Accepted: 07/19/2022] [Indexed: 02/08/2023]
Abstract
The acute respiratory distress syndrome (ARDS) is a common critical illness syndrome with high morbidity and mortality. There are no proven pharmacological therapies for ARDS. The current definition of ARDS is based on shared clinical characteristics but does not capture the heterogeneity in clinical risk factors, imaging characteristics, physiology, timing of onset and trajectory, and biology of the syndrome. There is increasing interest within the ARDS clinical trialist community to design clinical trials that reduce heterogeneity in the trial population. This effort must be balanced with ongoing work to craft an inclusive, global definition of ARDS, with important implications for trial design. Ultimately, the two aims-to design trials that are applicable to the diverse global ARDS population while also advancing opportunities to identify targetable traits-should coexist. In this Personal View, we recommend two primary strategies to improve future ARDS trials: the development of new methods to target treatable traits in clinical trial populations, and improvements in the representativeness of ARDS trials, with the inclusion of global populations. We emphasise that these two strategies are complementary. We also discuss how a proposed expansion of the definition of ARDS could affect the future of clinical trials.
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Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Neil R Aggarwal
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Aurora, CO, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Samir Jaber
- University Hospital, CHU de Montpellier Hôpital Saint Eloi, Intensive Care Unit and Transplantation, Department of Anesthesiology DAR B, Montpellier, France
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Nathalie Lassau
- Department of Imaging, Gustave Roussy, Université Paris Saclay, Villejuif, France; Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris Saclay, Villejuif, France
| | - Pierre François Laterre
- Intensive Care Medicine, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, Inserm, UMRS 1166-ICAN, Sorbonne University, Paris, France; Cardiac Surgery Service, Institute of Cardiology, AP-HP, Sorbonne University, Paris, France
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | | | - Pratik Sinha
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA; Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA.
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The Efficacy and Safety of In-Intensive Care Unit Leg-Cycle Ergometry in Critically Ill Adults. A Systematic Review and Meta-analysis. Ann Am Thorac Soc 2021; 17:1289-1307. [PMID: 32628501 DOI: 10.1513/annalsats.202001-059oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Survivors of critical illness may experience physical-function deficits after intensive care unit (ICU) discharge. In-ICU cycle ergometry may facilitate early mobilization and decrease functional impairment.Objective: We conducted a systematic review and meta-analysis to understand the effect of in-ICU leg-cycle ergometry on patient-important and clinically relevant outcomes.Data Sources: We searched eight electronic databases from inception until July 2019.Data Extraction: We included randomized controlled trials (RCTs) and nonrandomized studies of critically ill adults admitted to the ICU for ≥24 hours, comparing cycling interventions to control arms that did not receive cycling. Main outcomes included physical function, mechanical ventilation (MV) duration, length of stay (LOS), quality of life (QoL), mortality, and safety. We conducted independent duplicate-citation screening, data abstraction, and risk-of-bias assessments. We pooled RCTs using a random-effects model and calculated the risk ratio (RR), mean difference (MD), or standardized MD with 95% confidence intervals (CIs). We assessed certainty of outcomes using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: Of 6,531 citations, we included 12 RCTs and 2 nonrandomized studies (n = 926). Between the cycling and control groups, there were no differences in physical function at hospital discharge (3 RCTs; n = 225; standardized MD, 0.07 [95% CI, -0.38 to 0.53]; very low certainty), MV duration (9 RCTs; n = 676; MD, 0.01 [-1.04 to 1.07] days; moderate certainty), ICU LOS (10 RCTs; n = 511; MD, 0.23 [-1.44 to 1.89] days; moderate certainty), hospital LOS (7 RCTs; n = 393, MD -0.07 [-3.87 to 3.73] days; moderate certainty), QoL at 6 months after hospital discharge (2 RCTs; n = 103; MD, 9.13 [13.80 to 32.05] points higher; very low certainty), or hospital mortality (7 RCTs; n = 710; RR 1.09 [0.82 to 1.46]; moderate-certainty). The adverse event rate in cycling sessions was 0.16% across studies (10 studies; 5 of 3,117 sessions; very low certainty).Conclusions: Cycling initiated in the ICU is probably safe; however, we did not find any differences in physical function, MV duration, LOS, QoL, or mortality compared with those not receiving cycling. Rigorously designed RCTs are needed to improve precision and further investigate the effect of cycling on patient-important outcomes.
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Historic Abuses, Present Disparities, and Systemic Racism: Threats to Surrogate Decision-making for Critical Care Research Enrollment. Ann Am Thorac Soc 2021; 18:1118-1120. [PMID: 34242151 PMCID: PMC8328362 DOI: 10.1513/annalsats.202103-386ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gibbs KW, Chuang Key CC, Belfield L, Krall J, Purcell L, Liu C, Files DC. Aging Influences the Metabolic and Inflammatory Phenotype in an Experimental Mouse Model of Acute Lung Injury. J Gerontol A Biol Sci Med Sci 2021; 76:770-777. [PMID: 32997738 PMCID: PMC8087268 DOI: 10.1093/gerona/glaa248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Indexed: 01/16/2023] Open
Abstract
Increased age is a risk factor for poor outcomes from respiratory failure and acute respiratory distress syndrome (ARDS). In this study, we sought to define age-related differences in lung inflammation, muscle injury, and metabolism after intratracheal lipopolysaccharide (IT-LPS) acute lung injury (ALI) in adult (6 months) and aged (18-20 months) male C57BL/6 mice. We also investigated age-related changes in muscle fatty acid oxidation (FAO) and the consequences of systemic FAO inhibition with the drug etomoxir. Aged mice had a distinct lung injury course characterized by prolonged alveolar neutrophilia and lack of response to therapeutic exercise. To assess the metabolic consequences of ALI, aged and adult mice underwent whole body metabolic phenotyping before and after IT-LPS. Aged mice had prolonged anorexia and decreased respiratory exchange ratio, indicating increased reliance on FAO. Etomoxir increased mortality in aged but not adult ALI mice, confirming the importance of FAO on survival from acute severe stress and suggesting that adult mice have increased resilience to FAO inhibition. Skeletal muscles from aged ALI mice had increased transcription of key fatty acid metabolizing enzymes, CPT-1b, LCAD, MCAD, FATP1 and UCP3. Additionally, aged mice had increased protein levels of CPT-1b at baseline and after lung injury. Surprisingly, CPT-1b in isolated skeletal muscle mitochondria had decreased activity in aged mice compared to adults. The distinct phenotype of aged ALI mice has similar characteristics to the adverse age-related outcomes of ARDS. This model may be useful to examine and augment immunologic and metabolic abnormalities unique to the critically ill aged population.
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Affiliation(s)
- Kevin W Gibbs
- Department of Internal Medicine, Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Wake Forest Critical Illness, Injury, and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chia-Chi Chuang Key
- Department of Internal Medicine, Molecular Medicine, Wake Forest School of Medicine Winston-Salem, North Carolina
| | - Lanazha Belfield
- Department of Internal Medicine, Molecular Medicine, Wake Forest School of Medicine Winston-Salem, North Carolina
| | - Jennifer Krall
- Department of Internal Medicine, Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lina Purcell
- Department of Internal Medicine, Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chun Liu
- Department of Internal Medicine, Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - D Clark Files
- Department of Internal Medicine, Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Wake Forest Critical Illness, Injury, and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Krutsinger DC, O’Leary KL, Ellenberg SS, Cotner CE, Halpern SD, Courtright KR. A Randomized Controlled Trial of Behavioral Nudges to Improve Enrollment in Critical Care Trials. Ann Am Thorac Soc 2020; 17:1117-1125. [PMID: 32441987 PMCID: PMC7462327 DOI: 10.1513/annalsats.202003-194oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/21/2020] [Indexed: 01/04/2023] Open
Abstract
Rationale: Low and slow patient enrollment remains a barrier to critical care randomized controlled trials (RCTs). Behavioral economic insights suggest that nudges may address some enrollment challenges.Objectives: To evaluate the efficacy of a novel preconsent survey consisting of nudges on critical care RCT enrollment.Methods: We conducted an RCT in 10 intensive care units (ICUs) among surrogate decision-makers (SDMs). The novel multicomponent behavioral nudge survey was administered immediately before soliciting SDMs' informed consent for their patients' participation in a sham trial of two mechanical ventilation weaning approaches in acute respiratory failure. The primary outcome was the enrollment rate for the sham trial. Secondary outcomes included undue and unjust inducements. We also explored SDM and patient predictors of enrollment using multivariate regression.Results: Among 182 SDMs, 93 were randomized to receive the intervention survey and 89 to receive standard informed consent. There was no statistically significant difference in enrollment rates between the intervention (29%) and standard consent (34%) groups (percentage difference, 5%; 95% confidence interval [CI], -9% to 18%; P = 0.50). There was no evidence of undue or unjust inducement. White SDMs were more likely to enroll the patient compared with non-white SDMs (odds ratio, 3.7; 95% CI, 1.1 to 12.2; P = 0.03). SDMs who perceived a higher risk of participation were less likely to enroll the patient (odds ratio, 0.57; 95% CI, 0.46 to 0.71; P < 0.001).Conclusions: A preconsent behavioral nudge survey among SDMs of patients with acute respiratory failure in the ICU did not increase enrollment rates for a sham RCT compared with standard informed consent procedures.Clinical trial registered with ClinicalTrials.gov (NCT03284359).
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Affiliation(s)
- Dustin C. Krutsinger
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | | | - Scott D. Halpern
- Department of Biostatistics, Epidemiology, and Informatics
- Palliative and Advanced Illness Research Center
- Fostering Improvement in End-of-Life Decision Science Program
- Center for Health Incentives and Behavioral Economics
- Leonard Davis Institute of Health Economics, and
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Katherine R. Courtright
- Palliative and Advanced Illness Research Center
- Fostering Improvement in End-of-Life Decision Science Program
- Center for Health Incentives and Behavioral Economics
- Leonard Davis Institute of Health Economics, and
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
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8
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Richards-Belle A, Mouncey PR, Grieve RD, Harrison DA, Sadique MZ, Henry D, Whitman C, Camsooksai J, Gordon AC, Young JD, Rowan KM, Lamontagne F. Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Protocol for the 65 randomised clinical trial. J Intensive Care Soc 2019. [DOI: 10.1177/1751143719870088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragmatic, multi-centre, parallel-group, open-label, randomised clinical trial of permissive hypotension (a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial is conducted in 2600 patients from 65 United Kingdom adult, general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. The 65 trial received favourable ethical opinion from the South Central – Oxford C Research Ethics Committee and approval from the Health Research Authority. The results will be presented at national and international conferences and published in peer-reviewed medical journals. Trial registration: ISRCTN10580502
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Julie Camsooksai
- Critical Care, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, South Kensington Campus, London, UK
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Paddington, London, UK
| | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - François Lamontagne
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
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9
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Shepherd V, Wood F, Griffith R, Sheehan M, Hood K. Protection by exclusion? The (lack of) inclusion of adults who lack capacity to consent to research in clinical trials in the UK. Trials 2019; 20:474. [PMID: 31382999 PMCID: PMC6683336 DOI: 10.1186/s13063-019-3603-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/19/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Around two million adults in the UK have significantly impaired decision-making capacity. However, there are concerns that this population is under-represented in research, due in part to the challenges around obtaining consent. Under-representation of populations denies those who would have wanted to participate the opportunity to make a contribution to society, but also fails to generate results that are applicable to them. Consequently, the evidence base for their care is poorer than for other populations. We recently published in this journal an analysis of Participant Information Sheets provided to consultees and legal representatives of adults who lack capacity and noted the small number of trials designed to include adults who lack capacity. In order to understand how many adults who lack capacity to consent are actually enrolled in clinical trials, we further explored how many of the participants lacked capacity, and who acted as a consultee or legal representative on their behalf. MAIN TEXT The ISRCTN registry was searched for UK clinical trials in conditions commonly associated with cognitive impairment that were designed to include (or not exclude) adults who lack capacity to consent. Details about participants and capacity status were obtained from published data or directly from the trial teams. Of the 80 retrieved clinical trials that had completed in the previous 3 years, we identified 15 which included adults who lack capacity to consent. Data regarding participants' capacity status were not available for five trials. Where capacity was reported, 5-100% participants lacked capacity to consent. Trials predominantly utilised personal consultees/legal representatives; however, 39% (634/1631) of participants required a professional to act as consultee/legal representative. CONCLUSIONS Only a small number of trials including adults who lacked capacity were identified. The majority of participants were represented by a personal consultee/legal representative; however, between 21 and 100% of participants across five trials required the involvement of a professional, suggesting it is not uncommon. Data relating to capacity status were rarely reported, potentially masking the under-representation of adults who lack capacity. The findings may help researchers and funders target resources towards studies involving under-represented populations to increase the much-needed evidence base for their care and treatment.
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Affiliation(s)
- Victoria Shepherd
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS UK
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Fiona Wood
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS UK
| | - Richard Griffith
- College of Human and Health Studies, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Mark Sheehan
- Ethox Centre, University of Oxford, Big Data Institute, Old Road Campus, Oxford, OX3 7LF UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
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Kritchevsky SB, Forman DE, Callahan KE, Ely EW, High KP, McFarland F, Pérez-Stable EJ, Schmader KE, Studenski SA, Williams J, Zieman S, Guralnik JM. Pathways, Contributors, and Correlates of Functional Limitation Across Specialties: Workshop Summary. J Gerontol A Biol Sci Med Sci 2019; 74:534-543. [PMID: 29697758 PMCID: PMC6417483 DOI: 10.1093/gerona/gly093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/25/2022] Open
Abstract
Traditional clinical care models focus on the measurement and normalization of individual organ systems and de-emphasize aspects of health related to the integration of physiologic systems. Measures of physical, cognitive and sensory, and psychosocial or emotional function predict important health outcomes like death and disability independently from the severity of a specific disease, cumulative co-morbidity, or disease severity measures. A growing number of clinical scientists in several subspecialties are exploring the utility of functional assessment to predict complication risk, indicate stress resistance, inform disease screening approaches and risk factor interpretation, and evaluate care. Because a substantial number of older adults in the community have some form of functional limitation, integrating functional assessment into clinical medicine could have a large impact. Although interest in functional implications for health and disease management is growing, the science underlying functional capacity, functional limitation, physical frailty, and functional metrics is often siloed among different clinicians and researchers, with fragmented concepts and methods. On August 25-26, 2016, participants at a trans-disciplinary workshop, supported by the National Institute on Aging and the John A. Hartford Foundation, explored what is known about the pathways, contributors, and correlates of physical, cognitive, and sensory functional measures across conditions and disease states; considered social determinants and health disparities; identified knowledge gaps, and suggested priorities for future research. This article summarizes those discussions.
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Affiliation(s)
- Stephen B Kritchevsky
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Kathryn E Callahan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - E Wesley Ely
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC) and Department of Medicine, Vanderbilt University, Nashville
| | - Kevin P High
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Frances McFarland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | | | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Fan Y, Zhang H, Yang G, Wu C, Guo Y, Ling C. China’s cancer patients’ perceptions, attitudes and participation in clinical trials of complementary and alternative medicine: A multi-center cross-sectional study. Eur J Integr Med 2018. [DOI: 10.1016/j.eujim.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Afshar M, Netzer G, Mosier MJ, Cooper RS, Adams W, Burnham EL, Kovacs EJ, Durazo-Arvizu R, Kliethermes S. The Contributing Risk of Tobacco Use for ARDS Development in Burn-Injured Adults With Inhalation Injury. Respir Care 2017; 62:1456-1465. [PMID: 28900039 DOI: 10.4187/respcare.05560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aims to determine the relationship between tobacco use, inhalation injury, and ARDS in burn-injured adults. METHODS This study was an observational cohort of 2,485 primary burn admissions to a referral burn center between January 1, 2008 and March 15, 2015. Subjects were evaluated by methods used to account for mediation and traditional approaches (multivariable logistic regression and propensity score analysis). Mediation analysis examined both the (1) indirect effect of tobacco use via inhalation injury as the mediator on ARDS development and (2) the direct effect of tobacco use alone on ARDS development. RESULTS ARDS development occurred in 6.8% (n = 170) of the cohort. Inhalation injury occurred in 5.0% (n = 125) of the cohort, and ARDS developed in 48.8% (n = 83) of the subjects with inhalation injury. Tobacco use was 2-fold more common in subjects with ARDS. In the mediated model, the direct effect of tobacco use on ARDS, including interaction between tobacco use and inhalation injury, was not significant (odds ratio [OR] 1.63, 95% CI 0.91-2.92, P = .10). However, the indirect effect of tobacco use via inhalation injury as the mediator was significant (OR 1.61, 95% CI 1.25-2.07, P < .001), and the proportion of the total effect of tobacco use operating through the mediator was 55.6%. In the non-mediation models (multivariable logistic regression and propensity score analysis), which controlled for inhalation injury and other covariables, the OR for the association between tobacco use and ARDS was 1.84 (95% CI 1.22-2.81, P < .001) and 1.69 (95% CI 1.04-2.75, P = .03), respectively. CONCLUSIONS In mediation analysis, inhalation injury was the overwhelming predictor for ARDS development, whereas tobacco use has its strongest effect indirectly through inhalation injury. Patients with at least moderate inhalation injury are at greatest risk for ARDS development despite baseline risk factors like tobacco use.
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Affiliation(s)
- Majid Afshar
- Burn and Shock Trauma Research Institute .,Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, Illinois
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore Maryland
| | | | - Richard S Cooper
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - William Adams
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ramon Durazo-Arvizu
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Stephanie Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
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Shapiro ET, Schamel JT, Parker KA, Randall LA, Frew PM. The role of functional, social, and mobility dynamics in facilitating older African Americans participation in clinical research. OPEN ACCESS JOURNAL OF CLINICAL TRIALS 2017; 9:21-30. [PMID: 28804246 PMCID: PMC5552064 DOI: 10.2147/oajct.s122422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Older African Americans experience disproportionately higher incidence of morbidity and mortality related to chronic and infectious diseases, yet are significantly underrepresented in clinical research compared to other racial and ethnic groups. This study aimed to understand the extent to which social support, transportation access, and physical impediments function as barriers or facilitators to clinical trial recruitment of older African Americans. METHODS Participants (N=221) were recruited from six African American churches in Atlanta and surveyed on various influences on clinical trial participation. RESULTS Logistic regression models demonstrated that greater transportation mobility (odds ratio [OR]=2.10; p=0.007) and social ability (OR=1.77; p=0.02) were associated with increased intentions of joining a clinical trial, as was greater basic daily living ability (OR=3.25; p=0.03), though only among single participants. Among adults age ≥65 years, those with lower levels of support during personal crises were more likely to join clinical trials (OR=0.57; p=0.04). CONCLUSION To facilitate clinical trial entry, recruitment efforts need to consider the physical limitations of their potential participants, particularly basic physical abilities and disabilities. Crisis support measures may be acting as a proxy for personal health issues among those aged >65 years, who would then be more likely to seek clinical trials for the personal health benefits. Outreach to assisted living homes, hospitals, and other communities is a promising avenue for improved clinical trial recruitment of older African Americans.
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Affiliation(s)
- Eve T Shapiro
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, GA
| | - Jay T Schamel
- Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, GA
| | | | - Laura A Randall
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, GA
| | - Paula M Frew
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, GA
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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Kerkhoff LA, Butler J, Kelkar AA, Shore S, Speight CD, Wall LK, Dickert NW. Trends in Consent for Clinical Trials in Cardiovascular Disease. J Am Heart Assoc 2016; 5:JAHA.116.003582. [PMID: 27317350 PMCID: PMC4937285 DOI: 10.1161/jaha.116.003582] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Cardiovascular clinical trials depend on patient enrollment. Enrollment rates appear inadequate, but little is known about how frequently patients accept or decline offers of enrollment. The objective of this study was to assess trends and predictors of patient acceptance of offers to enroll in clinical trials for cardiovascular disease. Methods and Results We utilized an established database containing all randomized, controlled trials (n=1224) in cardiovascular disease published between 2001 and 2012 in the 8 highest‐impact general medical and cardiology journals. Studies were eligible if the number of patients approached and number of patients declining enrollment could be ascertained from published materials. All studies were screened for eligibility. Each eligible study was reviewed by 3 co‐authors. All discrepancies were resolved by the group. The main outcome was acceptance rate, defined as the number of patients enrolled divided by the number patients who were eligible and approached. Only 21.7% (n=266) of studies provided information sufficient to assess patient enrollment and refusals. The median acceptance rate across trials was 83.2%. Significant predictors of higher enrollment included: enrollment in the acute setting (P=0.031); geographical region (P<0.001 for group); and trial sponsorship (P=0.006 for group). Conclusions Rates of reporting data sufficient to calculate acceptance rates are low. This compromises the ability to identify drivers of low enrollment and assess trial generalizability. However, the high rates of acceptance observed suggest that factors other than patients’ decisions may be the primary drivers of declining rates of trial enrollment.
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Affiliation(s)
- Louis A Kerkhoff
- Medical College of Georgia-University of Georgia Medical Partnership, Augusta University, Athens, GA
| | - Javed Butler
- Division of Cardiology, Stony Brook University School of Medicine, Stony Brook, NY
| | - Anita A Kelkar
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Supriya Shore
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Candace D Speight
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Louisa K Wall
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Neal W Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
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Kho ME, Molloy AJ, Clarke F, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Pellizzari JR, Tarride JE, Mourtzakis M, Karachi T, Cook DJ. CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients. BMJ Open 2016; 6:e011659. [PMID: 27059469 PMCID: PMC4838736 DOI: 10.1136/bmjopen-2016-011659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT. METHODS AND ANALYSIS 60-patient parallel group pilot RCT in 7 Canadian medical-surgical ICUs. We will include all previously ambulatory adult patients within the first 0-4 days of mechanical ventilation, without exclusion criteria. After informed consent, patients will be randomised using a web-based, centralised electronic system, to 30 min of in-bed leg cycling in addition to routine physiotherapy, 5 days per week, for the duration of their ICU stay (28 days maximum) or routine physiotherapy alone. We will measure patients' muscle strength (Medical Research Council Sum Score, quadriceps force) and function (Physical Function in ICU Test (scored), 30 s sit-to-stand, 2 min walk test) at ICU awakening, ICU discharge and hospital discharge. Our 4 feasibility outcomes are: (1) patient accrual of 1-2 patients per month per centre, (2) protocol violation rate <20%, (3) outcome measure ascertainment >80% at the 3 time points and (4) blinded outcomes ascertainment >80% at hospital discharge. Hospital outcome assessors are blinded to group assignment, whereas participants, ICU physiotherapists, ICU caregivers, research coordinators and ICU outcome assessors are not blinded to group assignment. We will analyse feasibility outcomes with descriptive statistics. ETHICS AND DISSEMINATION Each participating centre will obtain local ethics approval, and results of the study will be published to inform the design and conduct of a future multicentre RCT of in-bed cycling to improve physical outcomes in ICU survivors. TRIAL REGISTRATION NUMBER NCT02377830; Pre-results.
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Affiliation(s)
- Michelle E Kho
- McMaster University, School of Rehabilitation Science, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander J Molloy
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - France Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K Y Koo
- Swedish Early Mobility Program in Critical Care, Swedish Medical Group, First Hill Campus, Seattle, Washington, USA
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Timothy Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Factors affecting patient participation in clinical trials in Ireland: A narrative review. Contemp Clin Trials Commun 2016; 3:23-31. [PMID: 29736453 PMCID: PMC5935836 DOI: 10.1016/j.conctc.2016.01.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 01/11/2016] [Accepted: 01/20/2016] [Indexed: 11/24/2022] Open
Abstract
Objective Clinical trials have long been considered the ‘gold standard’ of research generated evidence in health care. Patient recruitment is an important determinant in the success of the trials, yet little focus is placed on the decision making process of patients towards recruitment. Our objective was to identify the key factors pertaining to patient participation in clinical trials, to better understand the identified low participation rate of patients in one clinical research facility within Ireland. Design Narrative literature review of studies focussing on factors which may act to facilitate or deter patient participation in clinical trials. Studies were identified from Medline, PubMed, Cochrane Library and CINAHL. Results Sixty-one studies were included in the narrative review: Forty-eight of these papers focused specifically on the patient's perspective of participating in clinical trials. The remaining thirteen related to carers, family and health care professional perspectives of participation. The primary factor influencing participation in clinical trials amongst patients was related to personal factors and these were collectively associated with obtaining a form of personal gain through participation. Cancer was identified as the leading disease entity included in clinical trials followed by HIV and cardiovascular disease. Conclusion The vast majority of literature relating to participation in clinical trials emanates predominantly from high income countries, with 63% originating from the USA. No studies for inclusion in this review were identified from low income or developing countries and therefore limits the generalizability of the influencing factors.
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Hsieh SJ, Zhuo H, Benowitz NL, Thompson BT, Liu KD, Matthay MA, Calfee CS. Prevalence and impact of active and passive cigarette smoking in acute respiratory distress syndrome. Crit Care Med 2014; 42:2058-68. [PMID: 24942512 PMCID: PMC4134734 DOI: 10.1097/ccm.0000000000000418] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Cigarette smoke exposure has recently been found to be associated with increased susceptibility to trauma- and transfusion-associated acute respiratory distress syndrome. We sought to determine 1) the incidence of cigarette smoke exposure in a diverse multicenter sample of acute respiratory distress syndrome patients and 2) whether cigarette smoke exposure is associated with severity of lung injury and mortality in acute respiratory distress syndrome. DESIGN Analysis of the Albuterol for the Treatment of Acute Lung Injury and Omega Acute Respiratory Distress Syndrome Network studies. SETTING Acute Respiratory Distress Syndrome Network hospitals. PATIENTS Three hundred eighty-one patients with acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol, a validated tobacco-specific marker, was measured in urine samples from subjects enrolled in two National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network randomized controlled trials. Urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol levels were consistent with active smoking in 36% of acute respiratory distress syndrome patients and with passive smoking in 41% of nonsmokers (vs 20% and 40% in general population, respectively). Patients with 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol levels in the active smoking range were younger and had a higher incidence of alcohol misuse, fewer comorbidities, lower severity of illness, and less septic shock at enrollment compared with patients with undetectable 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol levels. Despite this lower severity of illness, the severity of lung injury did not significantly differ based on biomarker-determined smoking status. Cigarette smoke exposure was not significantly associated with death after adjusting for differences in age, alcohol use, comorbidities, and severity of illness. CONCLUSIONS In this first multicenter study of biomarker-determined cigarette smoke exposure in acute respiratory distress syndrome patients, we found that active cigarette smoke exposure was significantly more prevalent among acute respiratory distress syndrome patients compared to population averages. Despite their younger age, better overall health, and lower severity of illness, smokers by 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol had similar severity of lung injury as patients with undetectable 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol. These findings suggest that active cigarette smoking may increase susceptibility to acute respiratory distress syndrome in younger, healthier patients.
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Affiliation(s)
- S. Jean Hsieh
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Hanjing Zhuo
- Cardiovascular Research Institute, San Francisco, CA
| | - Neal L. Benowitz
- Division of Clinical Pharmacology and Experimental Therapeutics, University of California, San Francisco, California
- Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen D. Liu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
- Department of Anesthesia, University of California San Francisco, San Francisco, California
| | - Michael A. Matthay
- Cardiovascular Research Institute, San Francisco, CA
- Department of Anesthesia, University of California San Francisco, San Francisco, California
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco
| | - Carolyn S. Calfee
- Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California
- Department of Anesthesia, University of California San Francisco, San Francisco, California
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco
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Méan M, Righini M, Jaeger K, Beer HJ, Frauchiger B, Osterwalder J, Kucher N, Lämmle B, Cornuz J, Angelillo-Scherrer A, Rodondi N, Limacher A, Trelle S, Matter CM, Husmann M, Banyai M, Aschwanden M, Egloff M, Mazzolai L, Hugli O, Bounameaux H, Aujesky D. The Swiss cohort of elderly patients with venous thromboembolism (SWITCO65+): rationale and methodology. J Thromb Thrombolysis 2014; 36:475-83. [PMID: 23359097 DOI: 10.1007/s11239-013-0875-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Venous thromboembolism (VTE) is common and has a high impact on morbidity, mortality, and costs of care. Although most of the patients with VTE are aged ≥65 years, there is little data about the medical outcomes in the elderly with VTE. The Swiss Cohort of Elderly Patients with VTE (SWITCO65+) is a prospective multicenter cohort study of in- and outpatients aged ≥65 years with acute VTE from all five Swiss university and four high-volume non-university hospitals. The goal is to examine which clinical and biological factors and processes of care drive short- and long-term medical outcomes, health-related quality of life, and medical resource utilization in elderly patients with acute VTE. The cohort also includes a large biobank with biological material from each participant. From September 2009 to March 2012, 1,863 elderly patients with VTE were screened and 1003 (53.8%) were enrolled in the cohort. Overall, 51.7% of patients were aged ≥75 years and 52.7% were men. By October 16, 2012, after an average follow-up time of 512 days, 799 (79.7%) patients were still actively participating. SWITCO65+ is a unique opportunity to study short- and long-term outcomes in elderly patients with VTE. The Steering Committee encourages national and international collaborative research projects related to SWITCO65+, including sharing anonymized data and biological samples.
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Affiliation(s)
- Marie Méan
- Division of General Internal Medicine, Bern University Hospital, Inselspital, 3010, Bern, Switzerland,
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Abstract
OBJECTIVE To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. DATA SOURCES MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. STUDY SELECTION Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. DATA EXTRACTION Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness. DATA SYNTHESIS This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness. CONCLUSIONS The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.
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Affiliation(s)
- Graciela J Soto
- 1Division of Critical Care Medicine, Department of Medicine, Jay B. Langner Critical Care Service, Montefiore Medical Center, Bronx, NY. 2Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Grady Memorial Hospital, Atlanta, GA. 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
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Liang D, Sun Y, Shen Y, Li F, Song X, Zhou E, Zhao F, Liu Z, Fu Y, Guo M, Zhang N, Yang Z, Cao Y. Shikonin exerts anti-inflammatory effects in a murine model of lipopolysaccharide-induced acute lung injury by inhibiting the nuclear factor-kappaB signaling pathway. Int Immunopharmacol 2013; 16:475-80. [PMID: 23651796 DOI: 10.1016/j.intimp.2013.04.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/16/2013] [Accepted: 04/16/2013] [Indexed: 10/26/2022]
Abstract
Shikonin, an analog of naphthoquinone pigments isolated from the root of Lithospermum erythrorhyzon, was recently reported to exert beneficial anti-inflammatory effects both in vivo and in vitro. The present study aimed to investigate the potential therapeutic effect of shikonin in a murine model of lipopolysaccharide (LPS)-induced acute lung injury (ALI). Dexamethasone was used as a positive control to evaluate the anti-inflammatory effect of shikonin in the study. Pretreatment with shikonin (intraperitoneal injection) significantly inhibited LPS-induced increases in the macrophage and neutrophil infiltration of lung tissues and markedly attenuated myeloperoxidase activity. Furthermore, shikonin significantly reduced the concentrations of TNF-α, IL-6 and IL-1β in bronchoalveolar lavage fluid induced by LPS. Compared with the LPS group, lung histopathologic changes were less pronounced in the shikonin-pretreated mice. Additionally, Western blotting results showed that shikonin efficiently decreased nuclear factor-kappaB (NF-κB) activation by inhibiting the degradation and phosphorylation of IκBα. These results suggest that shikonin exerts anti-inflammatory properties in LPS-mediated ALI, possibly through inhibition of the NF-κB signaling pathway, which mediates the expression of pro-inflammatory cytokines. Shikonin may be a potential agent for the prophylaxis of ALI.
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Affiliation(s)
- Dejie Liang
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Jilin University, Changchun, Jilin Province 130062, People's Republic of China
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Voss R, Gravenstein S, Baier R, Butterfield K, Epstein-Lubow G, Shamji H, Gardner R. Recruiting hospitalized patients for research: how do participants differ from eligible nonparticipants? J Hosp Med 2013; 8:208-14. [PMID: 23559503 DOI: 10.1002/jhm.2024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/07/2013] [Accepted: 01/16/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Randomized controlled trials provide strong evidence for guidelines and interventions. Yet, much of the eligible population declines to be studied. OBJECTIVE To identify differences between participants and eligible nonparticipants in (1) perceived stress, (2) self-efficacy, (3) recovery expectations, (4) discussing advance directives, and (5) understanding a standard prescription label (health literacy). DESIGN Quasi-experimental prospective cohort study in 5 acute-care hospitals. METHODS We approached 295 hospital inpatients as they were being recruited for a behavioral intervention and asked them to answer 5 screening questions. We matched respondents' answers to their acceptance of the behavioral intervention and to Medicare claims and enrollment data. We used multivariate logistic regression to compare consent rates based on screening-question responses. SETTING/PATIENTS Hospitalized fee-for-service Medicare patients. RESULTS Patients were less likely to consent to the behavioral intervention when they reported feeling unable to control important things in their lives (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.14-0.92), had low recovery expectations (OR: 0.17, 95% CI: 0.06-0.45), or were confused by any question (OR: 0.11, 95% CI: 0.05-0.24). Conversely, individuals who answered the medication question incorrectly were more likely to consent to the behavioral intervention (OR: 3.82, 95% CI: 1.12-13.03). There were no significant differences in consent for patients who reported feeling overwhelmed or reported discussing advance care planning with family members or doctors. CONCLUSIONS Hospitalized eligible nonparticipants differ in constructs related to perceived stress, recovery expectation, and health literacy. Recognizing such characteristics may inform strategies to improve intervention recruitment in the hospital and representation in clinical trials.
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Affiliation(s)
- Rachel Voss
- Department of Health Services, Policy and Practice, Healthcentric Advisors, Providence, Rhode Island, USA
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Yeh EC, Mirocha JM, Brantman A, Ma XL, Qiao Y, Merz CNB, Jones HD. A Preliminary Investigation on the Acceptance and Feasibility of Acupuncture in the Intensive Care Unit. ACTA ACUST UNITED AC 2013. [DOI: 10.1177/1944451612472700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objective. Acupuncture has been shown to decrease opioid requirements and respiratory distress in selected patients, and it may be helpful as an adjunctive therapy to sedatives and analgesics in the ICU. This preliminary study investigated the acceptance and feasibility of acupuncture in the ICU. Design. Forty-eight patients in a 12-bed medical–surgical ICU at Cedars-Sinai Medical Center who met eligibility criteria were offered the opportunity to receive free-of-charge daily acupuncture treatments during their time in the ICU. Primary endpoints were percentage of patients offered acupuncture who accepted treatment, the percentage of eligible days acupuncture therapy was received, and the incidence of adverse events related to acupuncture treatment. Main Results. Of the 48 patients who were eligible and offered acupuncture therapy, 20 (41%) patients enrolled in the study with an average age of 56 years (range = 18-91 years). The median and average number of days which patients received acupuncture was 2 and 3, respectively (range = 0-11 days), and a majority of patients (13/20) received acupuncture for each of the days for which they were eligible. One patient reported dizziness, which resolved spontaneously and was not associated with hemodynamic changes. No other adverse effects occurred in a total of 64 acupuncture treatments. Conclusions. This preliminary study demonstrates that acupuncture therapy in the ICU is a feasible treatment modality. Further clinical trials are warranted to determine the efficacy of acupuncture therapy as an adjunct to sedative and analgesics in critically ill patients.
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Affiliation(s)
- Eugene C. Yeh
- Pulmonary Division, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - James M. Mirocha
- Biostatistics Core, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Anna Brantman
- Women’s Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiu Ling Ma
- Women’s Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yi Qiao
- Women’s Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - C. Noel Bairey Merz
- Women’s Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Heather D. Jones
- Pulmonary Division, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Research participants' opinions of delayed consent for a randomised controlled trial of glucose control in intensive care. Intensive Care Med 2012; 39:472-80. [PMID: 23096429 DOI: 10.1007/s00134-012-2732-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 09/18/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Critically ill patients are often unable to give informed consent to participate in clinical research. A process of delayed consent, enrolling patients into clinical trials and obtaining consent as soon as practical from either the participant or their substitute decision maker, has sometimes been used. The objective of this study was to determine the opinion of participants, previously enrolled in the NICE-SUGAR study, of the delayed consent process. METHODS This observational study was conducted from 2009 to 2010 in the ICU of a tertiary referral hospital in Australia. Participants who were enrolled in the NICE-SUGAR study with delayed consent who survived, were cognitively intact, and proficient in English were posted a questionnaire regarding their opinion of the delayed consent process. The questionnaire was returned by post, fax, email, or completed during a telephone interview. RESULTS Of 298 eligible participants, 210 responded, with an overall response rate of 79 %. Delayed consent to participate in the NICE-SUGAR study was obtained from participants (57/210; 27.1 %) or the substitute decision maker (152/210; 72.4 %). Most respondents (195/204; 95.6 %) would have consented to participate in the NICE-SUGAR study if asked before enrolment; most (163/198; 82.3 %) ranked first "the person who consented on their behalf for the NICE Study" as most preferred to make decisions, should they be unable; and most (177/202; 87.6 %) agreed with the decision made by their relative. CONCLUSION Delayed consent to participate in a clinical trial that includes critically ill patients is acceptable from research participant's perspectives.
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Jones CW, Hunold KM, Isaacs CG, Platts-Mills TF. Randomized trials in emergency medicine journals, 2008 to 2011. Am J Emerg Med 2012; 31:231-5. [PMID: 22867836 DOI: 10.1016/j.ajem.2012.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 06/01/2012] [Accepted: 06/02/2012] [Indexed: 01/24/2023] Open
Abstract
STUDY OBJECTIVE Knowledge of current areas of activity in emergency medicine research may improve collaboration among investigators and may help inform decisions about future research priorities. Randomized, controlled trials are a key component of research activity and an essential tool for improving care. We investigated the characteristics of randomized trials recently published in emergency medicine journals. METHODS This was a retrospective analysis of randomized trials published in the 5 highest impact emergency medicine journals. PubMed was searched for reports of randomized trials involving human subjects indexed to MEDLINE between January 1, 2008, and December 31, 2011. Included trials were classified with respect to study topic, funding source, presence of age-related inclusion criteria, and country of origin. RESULTS A total of 163 published studies were included for analysis. Pain management was the most commonly studied topic (n = 28, or 17%) followed by orthopedics (n = 24, or 15%), cardiovascular disease (n = 13, or 8%), and prehospital medicine (n = 13, or 8%). Less than half of studies received extramural funding support. Children were specifically examined in 22 (13%) of trials; only 5 trials (3%) specifically examined patients aged 60 or older. CONCLUSIONS Emergency medicine journals publish randomized trials addressing a wide range of clinical topics. Randomized trials focusing on geriatric patients are not commonly published in these journals.
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Affiliation(s)
- Christopher W Jones
- Department of Emergency Medicine, Christiana Care Hospital, Newark, DE 19718, USA.
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Cavassani SS, Junqueira VBC, Moraes JB, Luzo KK, Silva CMA, Barros M, Marinho M, Simões RS, Oliveira-Júnior IS. Short courses of mechanical ventilation with high-O2 levels in elderly rat lungs. Acta Cir Bras 2012; 26:107-13. [PMID: 21445472 DOI: 10.1590/s0102-86502011000200006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 12/20/2010] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the effects of mechanical ventilation (MV) of high-oxygen concentration in pulmonary dysfunction in adult and elderly rats. METHODS Twenty-eight adult (A) and elderly (E), male rats were ventilated for 1 hour (G-AV1 and G-EV1) or for 3 hours (G-AV3 and G-EV3). A and E groups received a tidal volume of 7 mL/kg, a positive end-expiratory pressure of 5 cm H2O, respiratory rate of 70 cycles per minute, and an inspiratory fraction of oxygen of 1. We evaluated total protein content and malondialdehyde in bronchoalveolar lavages (BAL) and performed lung histomorphometrical analyses. RESULTS In G-EV1 animals, total protein in BAL was higher (33.0±1.9 µg/mL) compared with G-AV1 (23.0±2.0 µg/mL). Upon 180 minutes of MV, malondialdehyde levels increased in elderly (G-EV3) compared with adult (G-AV3) groups. Malondialdehyde and total proteins in BAL after 3 hours of MV were higher in elderly group than in adults. In G-EV3 group we observed alveolar septa dilatation and significative increase in neutrofiles number in relation to adult group at 60 and 180 minutes on MV. CONCLUSION A higher fraction of inspired oxygen in short courses of mechanical ventilation ameliorates the parameters studied in elderly lungs.
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McMurdo MET, Roberts H, Parker S, Wyatt N, May H, Goodman C, Jackson S, Gladman J, O'Mahony S, Ali K, Dickinson E, Edison P, Dyer C. Improving recruitment of older people to research through good practice. Age Ageing 2011; 40:659-65. [PMID: 21911335 DOI: 10.1093/ageing/afr115] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is widespread evidence both of the exclusion of older people from clinical research, and of under-recruitment to clinical trials. This review and opinion piece provides practical advice to assist researchers both to adopt realistic, achievable recruitment rates and to increase the number of older people taking part in research. It analyses 14 consecutive recently published trials, providing the number needed to be screened to recruit one older participant (around 3:1), numbers excluded (up to 49%), drop out rates (5-37%) and whether the planned power was achieved. The value of planning and logistics are outlined, and approaches to optimising recruitment in hospital, primary care and care home settings are discussed, together with the challenges of involving older adults with mental incapacity and those from minority groups in research. The increasingly important task of engaging older members of the public and older patients in research is also discussed. Increasing the participation of older people in research will improve the generalisability of research findings and inform best practice in the clinical management of the growing older population.
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Affiliation(s)
- Marion E T McMurdo
- Ageing and Health, Ninewells Hospital and Medical School, University of Dundee, UK.
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Short-term mortality prediction for acute lung injury patients: external validation of the Acute Respiratory Distress Syndrome Network prediction model. Crit Care Med 2011; 39:1023-8. [PMID: 21761595 DOI: 10.1097/ccm.0b013e31820ead31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE An independent cohort of patients with acute lung injury was used to evaluate the external validity of a simple prediction model for short-term mortality previously developed using data from Acute Respiratory Distress Syndrome Network (ARDSNet) trials. DESIGN Data for external validation were obtained from a prospective cohort study of patients with acute lung injury. SETTING Thirteen intensive care units at four teaching hospitals in Baltimore, MD. PATIENTS Five hundred and eight nontrauma patients with acute lung injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 508 patients eligible for this analysis, 234 (46%) died inhospital. Discrimination of the ARDSNet prediction model for inhospital mortality, evaluated by the area under the receiver operator characteristic curves, was 0.67 for our external validation data set vs. 0.70 and 0.68 using Acute Physiology and Chronic Health Evaluation II and the ARDSNet validation data set, respectively. In evaluating calibration of the model, predicted vs. observed inhospital mortality for the external validation data set was similar for both low-risk (ARDSNet model score = 0) and high-risk (score = 3 or 4+) patient strata. However, for intermediate-risk (score = 1 or 2) patients, observed inhospital mortality was substantially higher than predicted mortality (25.3% vs. 16.5% and 40.6% vs. 31.0% for score = 1 and 2, respectively). Sensitivity analyses limiting our external validation data set to only those patients meeting the ARDSNet trial eligibility criteria and to those who received mechanical ventilation in compliance with the ARDSNet ventilation protocol did not substantially change the model's discrimination or improve its calibration. CONCLUSIONS Evaluation of the ARDSNet prediction model using an external acute lung injury cohort demonstrated similar discrimination of the model as was observed with the ARDSNet validation data set. However, there were substantial differences in observed vs. predicted mortality among intermediate-risk patients with acute lung injury. The ARDSNet model provided reasonable, but imprecise, estimates of predicted mortality when applied to our external validation cohort of patients with acute lung injury.
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Health-care system distrust in the intensive care unit. J Crit Care 2011; 27:3-10. [PMID: 21715134 DOI: 10.1016/j.jcrc.2011.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/11/2011] [Accepted: 04/29/2011] [Indexed: 11/21/2022]
Abstract
PURPOSE To examine the performance and properties of the Revised Health Care System Distrust Scale among surrogates in the intensive care unit (ICU). MATERIALS AND METHODS Pilot, prospective cohort study of 50 surrogates of adult, mechanically ventilated patients surveyed on days 1, 3, and 7 of ICU admission. RESULTS Responses on the Health Care System Distrust Scale on day 1 ranged from 9 to 34 (possible range 9-45, with higher scores indicating more distrust), with a mean and SD of 20.3 ± 6.9. Factor analysis demonstrated a 2-factor structure, corresponding to the domains of values and competence. Cronbach α for the overall scale was .83, for the competence subscale, .76, and for the values subscale, .74. Health-care system distrust was inversely correlated with trust in ICU physicians (Pearson coefficient -.63). When evaluated over the course of each patient's ICU stay, health-care system distrust ratings decreased by 0.31 per patient-day (95% CI 0.55-0.06, P = .015). Correlation between health-care system distrust and trust in ICU physicians decreased slightly over time. CONCLUSIONS Among surrogates in the ICU, the Health Care System Distrust Scale has high internal consistency and convergent validity. There was substantial variability in surrogates' trust in the health-care system.
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Examining disparities in Acute Respiratory Distress Network trial enrollment: Moving closer to evidence-based medicine*. Crit Care Med 2010; 38:1493-4. [DOI: 10.1097/ccm.0b013e3181e08fef] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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