Randomisation methods in controlled trials

The Additional Effect of Training Above the Maximal Metabolic Steady State on VO2peak, Wpeak and Time-Trial Performance in Endurance-Trained Athletes: A Systematic Review, Meta-analysis, and Reality Check

BACKGROUND

To improve sport performance, athletes use training regimens that include exercise below and above the maximal metabolic steady state (MMSS).

OBJECTIVE

The objective of this review was to determine the additional effect of training above MMSS on VO2peak, Wpeak and time-trial (TT) performance in endurance-trained athletes.

METHODS

Studies were included in the review if they (i) were published in academic journals, (ii) were in English, (iii) were prospective, (iv) included trained participants, (v) had an intervention group that contained training above and below MMSS, (vi) had a comparator group that only performed training below MMSS, and (vii) reported results for VO2peak, Wpeak, or TT performance. Medline and SPORTDiscus were searched from inception until February 23, 2023.

RESULTS

Fourteen studies that ranged from 2 to 12 weeks were included in the review. There were 171 recreational and 128 competitive endurance athletes. The mean age and VO2peak of participants ranged from 15 to 43 years and 38 to 68 mL·kg-1·min-1, respectively. The inclusion of training above MMSS led to a 2.5 mL·kg-1·min-1 (95% CI 1.4-3.6; p < 0.01; I2 = 0%) greater improvement in VO2peak. A minimum of 81 participants per group would be required to obtain sufficient power to determine a significant effect (SMD 0.44) for VO2peak. No intensity-specific effect was observed for Wpeak or TT performance, in part due to a smaller sample size.

CONCLUSION

A single training meso-cycle that includes training above MMSS can improve VO2peak in endurance-trained athletes more than training only below MMSS. However, we do not have sufficient evidence to conclude that concurrent adaptation occurs for Wpeak or TT performance.

Directed acyclic graph for epidemiological studies in childhood food allergy: Construction, user's guide, and application

Understanding modifiable prenatal and early life causal determinants of food allergy is important for the prevention of the disease. Randomized clinical trials studying environmental and dietary determinants of food allergy may not always be feasible. Identifying risk/protective factors for early-life food allergy often relies on observational studies, which may be affected by confounding bias. The directed acyclic graph (DAG) is a causal diagram useful to guide causal inference from observational epidemiological research. To date, research on food allergy has made little use of this promising method. We performed a literature review of existing evidence with a systematic search, synthesized 32 known risk/protective factors, and constructed a comprehensive DAG for early-life food allergy development. We present an easy-to-use online tool for researchers to re-construct, amend, and modify the DAG along with a user's guide to minimize confounding bias. We estimated that adjustment strategies in 57% of previous observational studies on modifiable factors of childhood food allergy could be improved if the researchers determined their adjustment sets by DAG. Future researchers who are interested in the causal inference of food allergy development in early life can apply the DAG to identify covariates that should and should not be controlled in observational studies.

Temporary Partial Weight-Bearing Restriction in Elderly Patients Treated With a Plate Fixation After a Distal Femur Fracture had a Negative Long-Term Impact on Gait Recovery

Background

Restricted weight-bearing is still used after lower extremity fracture surgery in elderly patients. The long-term effect on gait recovery in elderly patients with distal femur fractures (DFF) and their ability to comply with the restrictive weight-bearing regime is unknown. This study aimed to investigate the effect of restricted postoperative weight-bearing on gait recovery (actual weight-bearing and cadence) during a 1-year follow-up.

Methods

This study evaluated secondary outcomes from a randomized controlled trial (32 patients ≥65 years, with a traumatic DFF). Internal fixation was achieved using an anatomical lateral plate. Patients were allocated to either immediate full weight-bearing (FWB) or partial weight-bearing (PWB) (30% of body weight) for 8 weeks. Pressure-sensitive sensors (F-scan™ system, Tekscan, Massachusetts, USA) were used to measure weight-bearing and cadence postoperatively and at 8-, 16-, and 52-week follow-ups. Twenty-six patients with at least 1 measurement were included.

Results

There was a statistically significant difference in actual weight-bearing between the PWB and FWB groups postoperatively of 32.3% (95% confidence interval CI, -50.0; -13.0, P < .001) and at the 8-week follow-up of 36.8% (95% CI -61.0; -18.0, P = .01), but not at later follow-ups. The PWB group presented a consistently lower cadence compared to the FWB group, which was statistically significant at the 16-week follow-up with 9.0 steps/min (95% CI -16.2; -1.1, P = .047) and 52-week follow-up with 9.3 steps/min (95% CI -18.0; -3.9, P = .009).

Conclusions

Restricting postoperative weight-bearing in elderly patients with a DFF had a significant effect on postoperative weight-bearing. The effect lingered with a delayed return to FWB and persistent significantly lower cadence in the PWB group. These findings suggest that even temporary weight-bearing restrictions most likely have negative long-term effects on gait function at 1 year and, therefore, cannot be recommended.

Patients' Individualized Care Perceptions and Health Literacy Using an Interactive App During Breast and Prostate Cancer Treatment: Two Parallel Randomized Controlled Trials

The use of symptom management mobile apps can reduce patients' symptom burden during cancer treatment, but the evidence is lacking about their effect on care. Moreover, if patients' health literacy can be improved, it needs to be more rigorously tested. This study aimed to evaluate patients' perceptions of individualized care and health literacy using an interactive app in two randomized trials. Patients undergoing neoadjuvant chemotherapy for breast cancer (N = 149) and radiotherapy for prostate cancer (N = 150) were consecutively included and randomized into one intervention or control group. Outcome measures were Individualized Care Scale, Swedish Functional Health Literacy Scale, and Swedish Communicative and Critical Health Literacy Scale. In the breast cancer trial, no group differences were observed regarding individualized care or health literacy. Most patients had sufficient health literacy levels. In the prostate cancer trial, intervention group patients rated higher perceived individualized care regarding decision control at follow-up than the control group. Less than half had sufficient health literacy levels and intervention group patients significantly improved their ability to seek, understand, and communicate health information. Education level explained significant variance in health literacy in both trials. Using an interactive app can positively affect individualization in care and health literacy skills among patients treated for prostate cancer, although further research is warranted.

Characteristics of baseline frequency data in spinal RCTs do not suggest widespread non-random allocation

BACKGROUND

Recent signs of fraudulent behaviour in spine RCTs have queried the integrity of trials in the field. RCTs are particularly important due to the weight they are accorded in guiding treatment decisions, and thus, ensuring RCTs' reliability is crucial. This study investigates the presence of non-random baseline frequency data in purported RCTs published in spine journals.

METHODS

A PubMed search was performed to obtain all RCTs published in four spine journals (Spine, The Spine Journal, the Journal of Neurosurgery Spine, and European Spine Journal) between Jan-2016 and Dec-2020. Baseline frequency data were extracted, and variable-wise p values were calculated using the Pearson Chi-squared test. These p values were combined for each study into study-wise p values using the Stouffer method. Studies with p values below 0.01 and 0.05 and those above 0.95 and 0.99 were reviewed. Results were compared to Carlisle's 2017 survey of anaesthesia and critical care medicine RCTs.

RESULTS

One hundred sixty-seven of the 228 studies identified were included. Study-wise p values were largely consistent with expected genuine randomized experiments. Slightly more study-wise p values above 0.99 were observed than expected, but a number of these had good explanations to account for that excess. The distribution of observed study-wise p values was more closely matched to the expected distribution than those in a similar survey of the anaesthesia and critical care medicine literature.

CONCLUSION

The data surveyed do not show evidence of systemic fraudulent behaviour. Spine RCTs in major spine journals were found to be consistent with genuine random allocation and experimentally derived data.

Propofol and thiopental for intravenous induction in neonates: Study protocol for a dose-finding trial

BACKGROUND

Propofol and thiopental are commonly used induction agents in neonatal anesthesia. Even though both hypnotics have been used off-label for many years, pharmacological knowledge regarding these agents is scarce in neonates. The significant variability in neonates' body composition, organ function, and maturation makes pharmacological studies highly relevant albeit challenging. As a result, there is currently limited data about the anesthetic induction dose of thiopental and propofol in neonates. In addition, a knowledge gap exists concerning the pharmacodynamics of induction doses.

OBJECTIVE

To determine the median effective anesthetic induction dose of propofol and thiopental in neonatal patients of different gestational and postnatal ages and evaluate the pharmacodynamics of the anesthesia induction doses on the neonatal systemic and cerebral hemodynamics.

METHODS

This is a single-center, prospective, open-label, interventional, dose-finding study, including neonatal patients from birth up to 28 postnatal days undergoing general anesthesia for surgical or diagnostic procedures. The patients will be stratified according to their gestational and postnatal age and allocated to one of the two trial arms: anesthesia induction with propofol or anesthesia induction with thiopental. We will use Dixon's up-and-down method to estimate the median effective anesthesia induction dose of both agents in neonates of different gestational and postnatal ages. In addition, we will study the relationship between anesthesia induction doses and changes in systemic and cerebral hemodynamics.

DISCUSSION

Alterations in the systemic and cerebral regional hemodynamics secondary to anesthesia induction may be harmful in neonates, especially premature and critically ill newborns, due to their immature organ systems, reduced physiological reserves, and impaired cerebral autoregulation. Perfusion homeostasis is considered one of the significant and modifiable determinants of anesthesia-related neurocognitive outcomes. Therefore, dose-finding and safety pharmacological studies of the anesthetic induction agents in neonates are urgently needed and acknowledged as a high priority by the European Medicine Agency. Estimating adequate induction doses to ensure optimal depth of anesthesia while avoiding systemic and cerebral hemodynamic disturbances will help ensure safe anesthesia and potentially improve anesthesia-related outcomes in this group of patients.

TRIAL REGISTRATION

EudraCT (EudraCT Identifier: 2019-001534-34), 05.07.2022.

AraCust: a Saudi Telecom Tweets corpus for sentiment analysis

Comparing Arabic to other languages, Arabic lacks large corpora for Natural Language Processing (Assiri, Emam & Al-Dossari, 2018; Gamal et al., 2019). A number of scholars depended on translation from one language to another to construct their corpus (Rushdi-Saleh et al., 2011). This paper presents how we have constructed, cleaned, pre-processed, and annotated our 20,0000 Gold Standard Corpus (GSC) AraCust, the first Telecom GSC for Arabic Sentiment Analysis (ASA) for Dialectal Arabic (DA). AraCust contains Saudi dialect tweets, processed from a self-collected Arabic tweets dataset and has been annotated for sentiment analysis, i.e.,manually labelled (k=0.60). In addition, we have illustrated AraCust's power, by performing an exploratory data analysis, to analyse the features that were sourced from the nature of our corpus, to assist with choosing the right ASA methods for it. To evaluate our Golden Standard corpus AraCust, we have first applied a simple experiment, using a supervised classifier, to offer benchmark outcomes for forthcoming works. In addition, we have applied the same supervised classifier on a publicly available Arabic dataset created from Twitter, ASTD (Nabil, Aly & Atiya, 2015). The result shows that our dataset AraCust outperforms the ASTD result with 91% accuracy and 89% F1avg score. The AraCust corpus will be released, together with code useful for its exploration, via GitHub as a part of this submission.

Nurse co-ordinated health and lifestyle modification for reducing multiple cardio-metabolic risk factors in regional adults: outcomes from the MODERN randomized controlled trial

BACKGROUND 

Nurse-led health and lifestyle modification programmes can prevent cardio-metabolic diseases and be advantageous where health disparities exist.

AIMS 

To assess the effectiveness of a nurse-driven health and lifestyle modification programme in improving cardio-metabolic risk parameters for higher-risk regional residing adults.

METHODS 

We conducted an open, parallel-group randomized controlled trial in two sites. Participants were aged 40-70 years with no prior cardiovascular disease who had any three or more of; central obesity, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure (BP) and dysglycaemia. Intervention participants received individual face-to-face and telephone coaching for improving cardio-metabolic risk. Control group participants received standard care and general information about risk factor management. The primary endpoint was the percentage of participants who achieved the target risk factor thresholds or clinically significant minimum changes for any three or more cardio-metabolic risk factors during 24 months of follow-up.

RESULTS 

Participant average age was 57.6 (SD 7.6) years, 61% were female and 71% were employed. The primary endpoint was achieved by 76% intervention (97 of 127) and 71% usual care (92 of 129) participants [adjusted risk ratio (RR): 1.08; 95% CI 0.94, 1.24; P = 0.298]. Improved BP in the intervention group was more likely than in the control group (84% vs. 65%) (adj. RR: 1.28; 95% CI 1.11, 1.48; P = 0.001) but no other cardio-metabolic component.

CONCLUSION 

Nurse intervention to modify cardio-metabolic risk parameters had no enhanced effectiveness compared with usual care. However, participation was associated with improvements in cardio-metabolic abnormalities, with particular emphasis on BP.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trial Registry (ACTRN12616000229471).

The acute physiological and perceptual effects of recovery interval intensity during cycling-based high-intensity interval training

Purpose

The current study sought to investigate the role of recovery intensity on the physiological and perceptual responses during cycling-based aerobic high-intensity interval training.

Methods

Fourteen well-trained cyclists (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{V}{\text{O}}_{{{\text{2peak}}}}$$\end{document}V˙O2peak: 62 ± 9 mL kg⁻¹ min⁻¹) completed seven laboratory visits. At visit 1, the participants’ peak oxygen consumption (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{V}{\text{O}}_{{{\text{2peak}}}}$$\end{document}V˙O2peak) and lactate thresholds were determined. At visits 2–7, participants completed either a 6 × 4 min or 3 × 8 min high-intensity interval training (HIIT) protocol with one of three recovery intensity prescriptions: passive (PA) recovery, active recovery at 80% of lactate threshold (80A) or active recovery at 110% of lactate threshold (110A).

Results

The time spent at > 80%, > 90% and > 95% of maximal minute power during the work intervals was significantly increased with PA recovery, when compared to both 80A and 110A, during both HIIT protocols (all P ≤ 0.001). However, recovery intensity had no effect on the time spent at > 90% \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{V}{\text{O}}_{{{\text{2peak}}}}$$\end{document}V˙O2peak (P = 0.11) or > 95% \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{V}{\text{O}}_{{{\text{2peak}}}}$$\end{document}V˙O2peak (P = 0.50) during the work intervals of both HIIT protocols. Session RPE was significantly higher following the 110A recovery, when compared to the PA and 80A recovery during both HIIT protocols (P < 0.001).

Conclusion

Passive recovery facilitates a higher work interval PO and similar internal stress for a lower sRPE when compared to active recovery and therefore may be the efficacious recovery intensity prescription.

Nutritional interventions for treating foot ulcers in people with diabetes

BACKGROUND

Foot ulcers in people with diabetes are non-healing, or poorly healing, partial, or full-thickness wounds below the ankle. These ulcers are common, expensive to manage and cause significant morbidity and mortality. The presence of a wound has an impact on nutritional status because of the metabolic cost of repairing tissue damage, in addition to the nutrient losses via wound fluid. Nutritional interventions may improve wound healing of foot ulcers in people with diabetes.

OBJECTIVES

To evaluate the effects of nutritional interventions on the healing of foot ulcers in people with diabetes.

SEARCH METHODS

In March 2020 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effect of nutritional interventions on the healing of foot ulcers in people with diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors, working independently, assessed included RCTs for their risk of bias and rated the certainty of evidence using GRADE methodology, using pre-determined inclusion and quality criteria.

MAIN RESULTS

We identified nine RCTs (629 participants). Studies explored oral nutritional interventions as follows: a protein (20 g protein per 200 mL bottle), 1 kcal/mL ready-to-drink, nutritional supplement with added vitamins, minerals and trace elements; arginine, glutamine and β-hydroxy-β-methylbutyrate supplement; 220 mg zinc sulphate supplements; 250 mg magnesium oxide supplements; 1000 mg/day omega-3 fatty acid from flaxseed oil; 150,000 IU of vitamin D, versus 300,000 IU of vitamin D; 250 mg magnesium oxide plus 400 IU vitamin E and 50,000 IU vitamin D supplements. The comparator in eight studies was placebo, and in one study a different dose of vitamin D. Eight studies reported the primary outcome measure of ulcer healing; only two studies reported a measure of complete healing. Six further studies reported measures of change in ulcer dimension, these studies reported only individual parameters of ulcer dimensions (i.e. length, width and depth) and not change in ulcer volume. All of the evidence identified was very low certainty. We downgraded it for risks of bias, indirectness and imprecision. It is uncertain whether oral nutritional supplement with 20 g protein per 200 mL bottle, 1 kcal/mL, nutritional supplement with added vitamins, minerals and trace elements, increases the proportion of ulcers healed at six months more than placebo (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.42 to 1.53). It is also uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement increases the proportion of ulcers healed at 16 weeks compared with placebo (RR 1.09, 95% CI 0.85 to 1.40). It is uncertain whether the following interventions change parameters of ulcer dimensions over time when compared with placebo; 220 mg zinc sulphate supplement containing 50 mg elemental zinc, 250 mg magnesium oxide supplement, 1000 mg/day omega-3 fatty acid from flaxseed oil supplement, magnesium and vitamin E co-supplementation and vitamin D supplementation. It is also uncertain whether 150,000 IU of vitamin D, impacts ulcer dimensions when compared with 300,000 IU of vitamin D. Two studies explored some of the secondary outcomes of interest for this review. It is uncertain whether oral nutritional supplement with 20 g protein per 200 mL bottle, 1 kcal/mL, nutritional supplement with added vitamins, minerals and trace elements, reduces the number of deaths (RR 0.96, 95% CI 0.06 to 14.60) or amputations (RR 4.82, 95% CI 0.24 to 95.88) more than placebo. It is uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement increases health-related quality of life at 16 weeks more than placebo (MD -0.03, 95% CI -0.09 to 0.03). It is also uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement reduces the numbers of new ulcers (RR 1.04, 95% CI 0.71 to 1.51), or amputations (RR 0.66, 95% CI 0.16 to 2.69) more than placebo. None of the included studies reported the secondary outcomes cost of intervention, acceptability of the intervention (or satisfaction) with respect to patient comfort, length of patient hospital stay, surgical interventions, or osteomyelitis incidence. One study exploring the impact of arginine, glutamine and β-hydroxy-β-methylbutyrate supplement versus placebo did not report on any relevant outcomes.

AUTHORS' CONCLUSIONS

Evidence for the impact of nutritional interventions on the healing of foot ulcers in people with diabetes compared with no nutritional supplementation, or compared with a different dose of nutritional supplementation, remains uncertain, with eight studies showing no clear benefit or harm. It is also uncertain whether there is a difference in rates of adverse events, amputation rate, development of new foot ulcers, or quality of life, between nutritional interventions and placebo. More research is needed to clarify the impact of nutritional interventions on the healing of foot ulcers in people with diabetes.

Refined experimental design may increase the value of murine models for estimation of bluetongue virus virulence

Bluetongue is a serious non-contagious vector-borne viral disease in ruminants, causing poor animal welfare and economic consequences globally. Concern has been raised about the development of novel bluetongue virus (BTV) strains and their possibly altered virulence through the process of viral reassortment. Virulence is traditionally estimated in lethal dose 50 (LD₅₀) studies in murine models, but agreement with both in vitro and virulence in ruminants is questionable, and a refined experimental design is needed. Specific reassortants between wild-type and vaccine strains of BTV-1, -6 and -8 have previously been developed by reverse genetics. The aim of the present study was to rank the in vivo virulence of these parental and reassortant BTV strains by calculating LD₅₀ in a murine model by using an experimental design that is new to virology: a between-patient optimised three-level response surface pathway design. The inoculation procedure was intracranial. Fifteen suckling mice were used to establish LD₅₀ for each strain. Three parental and five reassortant virus strains were included. The LD₅₀s varied from of 0.1 (95% confidence interval (CI) 0-0.20) to 3.3 (95% CI 2.96-3.72) tissue culture infectious dose 50/ml. The results support the hypothesis that reassortment in BTV may lead to increased virulence in mice with potential negative consequences for the natural ruminant host. The ranking showed low agreement with in vitro properties and virulence in ruminants according to existing literature. Refined design such as response surface pathway design was found suitable for use in virology, and it introduces significant ethical and scientific improvements.

Blame-rebalance fMRI neurofeedback in major depressive disorder: A randomised proof-of-concept trial

Previously, using fMRI, we demonstrated lower connectivity between right anterior superior temporal (ATL) and anterior subgenual cingulate (SCC) regions while patients with major depressive disorder (MDD) experience guilt. This neural signature was detected despite symptomatic remission which suggested a putative role in vulnerability. This randomised controlled double-blind parallel group clinical trial investigated whether patients with MDD are able to voluntarily modulate this neural signature. To this end, we developed a fMRI neurofeedback software (FRIEND), which measures ATL-SCC coupling and displays its levels in real time. Twenty-eight patients with remitted MDD were randomised to two groups, each receiving one session of fMRI neurofeedback whilst retrieving guilt and indignation/anger-related autobiographical memories. They were instructed to feel the emotion whilst trying to increase the level of a thermometer-like display on a screen. Active intervention group: The thermometer levels increased with increasing levels of ATL-SCC correlations in the guilt condition. Control intervention group: The thermometer levels decreased when correlation levels deviated from the previous baseline level in the guilt condition, thus reinforcing stable correlations. Both groups also received feedback during the indignation condition reinforcing stable correlations. We confirmed our predictions that patients in the active intervention group were indeed able to increase levels of ATL-SCC correlations for guilt vs. indignation and their self-esteem after training compared to before training and that this differed significantly from the control intervention group. These data provide proof-of-concept for a novel treatment target for MDD patients and are in keeping with the hypothesis that ATL-SCC connectivity plays a key role in self-worth.

https://clinicaltrials.gov/ct2/show/results/NCT01920490

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Employs real-time fMRI of anterior temporal –subgenual cingulate connectivity

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Previously decreased for guilt in major depressive disorder (MDD) beyond remission

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This RCT shows MDD patients can increase connectivity in one neurofeedback session.

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Active neurofeedback group increase self-esteem vs control neurofeedback group

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Training-induced self-esteem increases correlate with connectivity increases

Multicenter randomized controlled trial comparing the effectiveness and safety of hydrocellular and hydrocolloid dressings for treatment of category II pressure ulcers in patients at primary and long-term care institutions

BACKGROUND

Pressure ulcers are a major burden to patients because they affect health, well-being, and health-related quality of life. Thus, prevention and early treatment of pressure ulcers is a major challenge for health care professionals.

OBJECTIVE

To compare the efficacy of hydrocellular and hydrocolloid dressings after 8 weeks of treatment of category II pressure ulcers.

DESIGN

A prospective multicenter clinical trial with blinded outcome assessors.

PARTICIPANTS AND SETTINGS

Adult patients with category II pressure ulcers from primary and long-term care institutions on Majorca island.

METHODS

Category II ulcers were treated with ALLEVYN Adhesive^® dressings or VARIHESIVE^® GEL CONTROL dressings, with the primary outcome being healing of the ulcers in 8 weeks. Blinded confirmation of ulcer healing was performed by a treatment-group assessment committee. Estimates of cumulative survival probabilities were determined using the Kaplan-Meier method and analyses of effectiveness were performed using the chi-squared test.

RESULTS

A total of 169 patients with pressure ulcers were enrolled, 84 of whom received hydrocellular dressings and 85 of whom received hydrocolloid dressings. A total of 58% were women and 56% were from primary care institutions. The hydrocellular dressing group had a higher percentage of healed pressure ulcers at 8 weeks (90.7% vs. 77.1%, p = 0.039) and a shorter average healing time (3 weeks vs. 4 weeks, p = 0.015). Analysis of safety outcomes at 8 weeks indicated that the hydrocellular dressing group had a smaller proportion of ulcers that were unhealed (3.9% vs. 7.1%) and a smaller proportion of ulcers that progressed to a higher category or infection (5.3% vs. 15.7%), although these differences were not statistically significant.

CONCLUSIONS

This study of patients with category II pressure ulcers indicated that hydrocellular dressings were superior to hydrocolloid dressings in terms of healing at 8 weeks and time required for healing, although these two dressings had similar safety profiles.

Early mobilisation of patients with community-acquired pneumonia reduce length of hospitalisation-a pilot study

[Purpose] To examine if length of stay was reduced following an early mobilisation programme in patients with community-acquired pneumonia, and secondary, if such a program influenced short-term rehospitalisation and mortality rates. [Participants and Methods] Ninety seven consecutive patients (51% men; over all mean ± SD age 71.9 ± 16.5 years) with community-acquired pneumonia were included in the intervention group, and compared with a historical control group of 97 patients, matching at case level. Early mobilisation was defined as more than 20 minutes out of bed within 24 hours of hospitalisation. [Results] Eighty out of 97 patients in the intervention group were mobilised within 24 hours and length of stay for all patients was reduced with an average of 1.5 (95%CI: -0.2; 3.2) days compared to the control group. There was no significant difference between the two groups according to 30-day rehospitalisation and mortality. [Conclusion] An early mobilisation program seem to reduce the length of stay for patients with community-acquired pneumonia, and without an increase in short-term mortality and re-hospitalisation rates.

Re-inventing the randomized controlled trial in medical oncology: The registry-based trial

Substantial progress has recently been made in optimizing the management of cancer patients, resulting in major gains in survival and quality of life. Much of this progress has resulted from the serial testing of promising treatment strategies, typically using prospective randomized controlled trials to compare outcomes achieved with the new approach versus the current standard(s) of care. However, there is an ever-expanding list of important questions that are difficult to investigate, particularly with respect to determining the optimal sequencing and combination of proven active agents. With the rapidly growing list of clinical, pathologic and molecular characteristics that promise to predict treatment benefit and/or risk for defined patient subsets, many new questions regarding how best to personalize our approach to treatment selection are emerging. These questions can be investigated in the context of registry-based randomized clinical trials. Recently, the potential of registry-based randomized clinical trials was demonstrated in cardiology, highlighting the ability to rapidly recruit large numbers of patients to a trial addressing an important clinical question, with minimal cost and high external validity. In this review, we discuss the challenges and limitations of conventional clinical trials in multidisciplinary cancer care, describe the potential advantages of registry-based randomized trials, and highlight several registry-based oncology studies that are already underway to demonstrate the feasibility of this approach.

Transcranial direct current stimulation over left inferior frontal cortex improves speech fluency in adults who stutter

See Crinion (doi:10.1093/brain/awy075) for a scientific commentary on this article.Stuttering is a neurodevelopmental condition affecting 5% of children, and persisting in 1% of adults. Promoting lasting fluency improvement in adults who stutter is a particular challenge. Novel interventions to improve outcomes are of value, therefore. Previous work in patients with acquired motor and language disorders reported enhanced benefits of behavioural therapies when paired with transcranial direct current stimulation. Here, we report the results of the first trial investigating whether transcranial direct current stimulation can improve speech fluency in adults who stutter. We predicted that applying anodal stimulation to the left inferior frontal cortex during speech production with temporary fluency inducers would result in longer-lasting fluency improvements. Thirty male adults who stutter completed a randomized, double-blind, controlled trial of anodal transcranial direct current stimulation over left inferior frontal cortex. Fifteen participants received 20 min of 1-mA stimulation on five consecutive days while speech fluency was temporarily induced using choral and metronome-timed speech. The other 15 participants received the same speech fluency intervention with sham stimulation. Speech fluency during reading and conversation was assessed at baseline, before and after the stimulation on each day of the 5-day intervention, and at 1 and 6 weeks after the end of the intervention. Anodal stimulation combined with speech fluency training significantly reduced the percentage of disfluent speech measured 1 week after the intervention compared with fluency intervention alone. At 6 weeks after the intervention, this improvement was maintained during reading but not during conversation. Outcome scores at both post-intervention time points on a clinical assessment tool (the Stuttering Severity Instrument, version 4) also showed significant improvement in the group receiving transcranial direct current stimulation compared with the sham group, in whom fluency was unchanged from baseline. We conclude that transcranial direct current stimulation combined with behavioural fluency intervention can improve fluency in adults who stutter. Transcranial direct current stimulation thereby offers a potentially useful adjunct to future speech therapy interventions for this population, for whom fluency therapy outcomes are currently limited.

Sequence balance minimisation: minimising with unequal treatment allocations

BACKGROUND

Minimisation ensures excellent balance between groups for several prognostic factors, even in small samples. However, its use with unequal allocation ratios has been problematic. This paper describes a new minimisation scheme named sequence balance minimisation for unequal treatment allocations.

METHODS

Treatment- and factor-balancing properties were assessed in simulation studies for two- and three-arm trials with 1:2 and 1:2:3 allocation ratios. Sample sizes were set 30, 60 and 120. The number of prognostic factors on which to achieve balance was ranged from zero (treatment totals only) to ten with two levels occurring in equal probabilities. Random elements were set at 0.95, 0.9, 0.85, 0.80, 0.7, 0.6 and 0.5. Characteristics of the randomisation distributions and the impact of changing the block size while maintaining the allocation ratio were also examined.

RESULTS

Sequence balance minimisation has good treatment- and factor-balancing capabilities, and the randomisation distribution was centred at zero for all scenarios. The mean and median number of allocations achieved were the same as the number expected in most scenarios, and including additional factors (up to ten) in the minimisation scheme had little impact on treatment balance. Treatment balance tended to depart from the target as the random element was lowered. The variability in allocations achieved increased slightly as the number of factors increased, as the random element was decreased and as the sample size increased. The mean and median factor imbalance remained tightly around zero even when the chosen factor was not included in the minimisation scheme, though the variability was greater. The variability in factor imbalance increased slightly as the random element decreased, as well as when the number of prognostic factors and sample size increased. Increasing block size while maintaining the allocation ratio improved treatment balance notably with little impact on factor imbalance.

CONCLUSIONS

Sequence balance minimisation has good treatment- and factor-balancing properties and is particularly useful for small trials seeking to achieve balance across several prognostic factors.

Effects of health counseling on behavioural risk factors in a high-risk cardiology outpatient population: a randomized clinical trial

BACKGROUND

An evaluation study of an individual lifestyle advice intervention to reduce cardiovascular risk behaviours (high fat consumption, smoking, physical inactivity).

METHODS

A randomized, controlled trial at the cardiology outpatient clinic of the University Hospital Maastricht. Participants were at high risk of incurring a cardiovascular event. Changes in risk behaviours and behavioural determinants were assessed with self-administered validated questionnaires.

RESULTS

Questionnaires were completed by 1270 patients at baseline, 1169 after 4 months (92%), and 1032 after 18 months (81.3%). After 4 months, intention-to-treat analyses revealed a decrease in fat consumption (-5.6%, P = 0.000), a reduction in the percentage of smokers [odds ratio (OR) 0.57, 95% confidence intervals (CI) 0.33-0.97] and a trend towards a maintained physical activity level (OR 1.28, 95% CI 0.97-1.70). No long-term effects were found.

CONCLUSION

The lifestyle advice intervention was potentially effective in changing cardiovascular risk behaviours, but should be further improved to be effective in secondary cardiovascular prevention. The main limitations of the study were related to the randomization procedure and the self-selection of patients and cardiologists.

Computer Enabled Neuroplasticity Treatment: A Clinical Trial of a Novel Design for Neurofeedback Therapy in Adult ADHD

Background: We report a randomized controlled clinical trial of neurofeedback therapy intervention for ADHD/ADD in adults. We focus on internal mechanics of neurofeedback learning, to elucidate the primary role of cortical self-regulation in neurofeedback. We report initial results; more extensive analysis will follow.

Methods: Trial has two phases: intervention and follow-up. The intervention consisted of neurofeedback treatment, including intake and outtake measurements, using a waiting-list control group. Treatment involved ~40 h-long sessions 2–5 times per week. Training involved either theta/beta or sensorimotor-rhythm regimes, adapted by adding a novel “inverse-training” condition to promote self-regulation. Follow-up (ongoing) will consist of self-report and executive function tests.

Setting: Intake and outtake measurements were conducted at University of Helsinki. Treatment was administered at partner clinic Mental Capital Care, Helsinki.

Randomization: We randomly allocated half the sample then adaptively allocated the remainder to minimize baseline differences in prognostic variables.

Blinding: Waiting-list control design meant trial was not blinded.

Participants: Fifty-four adult Finnish participants (mean age 36 years; 29 females) were recruited after screening by psychiatric review. Forty-four had ADHD diagnoses, 10 had ADD.

Measurements: Symptoms were assessed by computerized attention test (T.O.V.A.) and self-report scales, at intake and outtake. Performance during neurofeedback trials was recorded.

Results: Participants were recruited and completed intake measurements during summer 2012, before assignment to treatment and control, September 2012. Outtake measurements ran April-August 2013. After dropouts, 23 treatment and 21 waiting-list participants remained for analysis.

Initial analysis showed that, compared to waiting-list control, neurofeedback promoted improvement of self-reported ADHD symptoms, but did not show transfer of learning to T.O.V.A. Comprehensive analysis will be reported elsewhere.

Trial Registration: “Computer Enabled Neuroplasticity Treatment (CENT),” ISRCTN13915109.

Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To evaluate the effects of high-velocity, low-amplitude thrust manipulations (HVLATMs) and various messages on patients with musculoskeletal shoulder symptoms.

BACKGROUND

Previous studies indicated that HVLATM directed at the thoracic spine and ribs resulted in improvements of shoulder range of motion, pain, and disability in patients with musculoskeletal shoulder symptoms. These studies did not explore if the outcome was dependent on thrust location, clinician communication with the patient, or if there were any lasting effects.

METHODS

A consecutive sample of 100 patients with shoulder pain was randomized into four groups. Patients received one intervention session including: six thoracic HVLATM (spine versus scapula), a message about HVLATM (neutral versus positive), and standardized home exercises. Outcome measures included shoulder Numeric Pain Rating Scale (NPRS), NPRS with impingement testing, and Shoulder Pain and Disability Index (SPADI). Measurements were recorded prior to intervention, immediately following intervention, and at short-term follow-up. Kruskal-Wallis statistics were used for between-group comparisons and Wilcoxon signed ranks for within-group comparisons.

RESULTS

Eighty-eight patients (22 per group) completed the study. Statistically significant differences were found for within-group comparisons for most time points assessed. No statistical differences were found for between-group comparisons.

CONCLUSION

Patients improved following the interventions. Neither the type of HVLATM nor the message conveyed to the patients had a significant effect on the patients' improvements.

LEVEL OF EVIDENCE

1b.

Evaluation of a Brief Personalised Intervention for Alcohol Consumption in College Students

In the current study we investigated the effect of a brief personalised feedback intervention (BPI), compared to an active control intervention, on outcome measures of (i) alcohol consumption (ii) frequency of binge drinking and (iii) readiness to change (RTC). A sample of 103 college students (mean age=23.85) who consumed alcohol regularly provided baseline measures of drinking behaviour and readiness to change before completing an alcohol-related quiz on the UK Department of Health's Change4Life website (active control). The study was a between subjects design and half the participants were randomly allocated to the BPI group (N=52), who received 10 minutes personalised feedback on their drinking in addition to the alcohol-related quiz. At a two-week follow-up, participants (N=103) repeated the questionnaire battery, and attempted to recall the answers to the alcohol quiz. Results indicated that both groups significantly reduced their alcohol consumption and frequency of binge drinking but there were no significant group differences in either of these measures. We conclude that the provision of generalised information can be as efficient as a BPI for the reduction of alcohol consumption in students.

A practical approach to evidence-based dentistry: III: how to appraise and use an article about therapy

BACKGROUND AND OVERVIEW

Dental practitioners spend most of their time administering treatments. To ensure that their clinical decisions are informed by the best available evidence, dental practitioners need to be skilled in critically appraising studies addressing therapy issues. Randomized controlled trials offer the optimal study design to inform decisions regarding therapy. The critical appraisal of randomized controlled trials involves assessing the risk of bias, results, and applicability. In this article, the authors present these concepts and provide guidance for this type of appraisal.

PRACTICAL IMPLICATIONS

Dentists who wish to inform their clinical decisions regarding therapy and prevention questions can use these guidelines to decide what type of studies to search, define the specific question of interest to search efficiently for these studies, and critically appraise an article about therapy or prevention.

A comparison of three types of web-based inhibition training for the reduction of alcohol consumption in problem drinkers: study protocol

Background

Problem drinkers have poor inhibitory control (disinhibition). Previous studies have demonstrated that various forms of ‘inhibition training’ can reduce alcohol consumption in the laboratory and at short-term follow-up, but their longer-term efficacy and mechanisms of action are unknown. In this phase 2 randomised controlled trial we will contrast the effects of three forms of inhibition training and a control intervention, delivered via the Internet in multiple sessions over four weeks, on alcohol consumption in heavy drinkers.

Methods/design

Heavy drinkers who are interested in reducing their alcohol consumption will receive a brief intervention and will monitor their own alcohol intake for one week before being randomised to one of four treatment groups: 1. General inhibition training; 2. Cue-Specific inhibition training; 3. Alcohol No-Go training; or 4. Control. They will complete up to 14 sessions of training via the Internet over a four-week period, and will be followed-up for a further six weeks after the end of the training period. Primary outcome measures are reductions in alcohol consumption and heavy drinking days. The number of abstinent days is a secondary outcome measure. We will also investigate changes in inhibitory control and automatic alcohol affective associations in response to training.

Discussion

This study will establish if web-based inhibition training can help problem drinkers to reduce their alcohol intake, and it will identify which form(s) of inhibition training are most effective.

Trial registation

Trial Registation number: ISRCTN55671858.

Evaluation of a complex intervention to improve activities of daily living of disabled cancer patients: protocol for a randomised controlled study and feasibility of recruitment and intervention

Background

Many cancer patients have problems performing activities of daily living (ADL). A randomised controlled trial was designed to examine the effects of an ADL intervention in addition to standard treatment and care in a hospital setting. The objective of this article was to present the study and to analyse the feasibility of the recruitment process and the intervention.

Methods

Adult disabled cancer patients at Næstved Hospital in Denmark were enrolled between 1 March 2010 and 30 June 2011 and randomised into an ADL intervention or to a control group. The intervention was performed by occupational therapists. The feasibility of the recruitment was analysed with regard to success in achieving the estimated number of participants and identification of barriers, and feasibility of the intervention was based on calculations of patient attendance and patient acceptability. The primary outcome of the randomised controlled trial was patients’ health-related quality of life 2 and 8 weeks after baseline.

Results

A total of 118 disabled cancer patients were enrolled in the study over a time span of 16 months. Very few meetings between occupational therapist and patient were cancelled. Time spent on the intervention varied considerably, but for the majority of patients, time consumption was between 1–3 hours.

Conclusions

Despite difficulties with recruitment, participation was considered feasible and the intervention was accepted among patients. Missing data in the follow-up period were mostly due to death among participants. Very few participants declined to complete questionnaires during follow-up.

Effect of minimally invasive percutaneous plates versus interlocking intramedullary nailing in tibial shaft treatment for fractures in adults: a meta-analysis

OBJECTIVE

The aim of this article was to determine the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults.

METHOD

Literature searches of the Cochrane Library, PubMed, EMBASE, the Chinese Biomedical Literature database, the CNKI database, Wanfang Data, and the Weipu Journal database were performed up to August 2013. Only randomized and quasi-randomized controlled clinical trials comparing the use of percutaneous plates and interlocking intramedullary nails for tibial shaft fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.

RESULTS

Eleven trials were included. Compared with interlocking intramedullary nailing, minimally invasive percutaneous plates shortened fracture healing time and resulted in lower rates of postoperative delayed union and pain. There was no significant difference between the two methods with regard to the rates of excellent and good Johner-Wruh scoring, the rate of reoperation, and other complications.

CONCLUSIONS

Overall, insufficient evidence exists regarding the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults. Low-quality evidence suggests that minimally invasive percutaneous plates could shorten fracture healing time, decrease the rate of postoperative delayed union, and decrease pain levels compared with interlocking intramedullary nailing. There is no significant difference between the two groups in terms of functional recovery scores, reoperation, and other complications. Further research that includes high-quality randomized controlled, multicenter trials is required to compare the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults.

A meta-analysis of the sub-vastus approach and medial parapatellar approach in total knee arthroplasty

PURPOSE

Both sub-vastus (SV) approach and standard medial parapatellar (MP) approach are performed in primary total knee arthroplasty (TKA). Proponents of SV approach stress its importance in decreasing lateral release and preserving function of the extensor mechanism with earlier rehabilitation. The purpose of this study was to summarize the best evidence to compare functional outcomes between SV approach and MP approach in TKA.

METHODS

All relevant randomized controlled trials and quasi-randomized controlled trails comparing SV approach and MP approach in primary TKA were included, and the search strategy followed the requirements of the Cochrane Library Handbook. Methodological quality was assessed, and data were extracted independently by two authors.

RESULTS

Ten studies involving 976 knees, which compared the clinical outcomes after TKA by SV approach and MP approach, were included. The results showed that the SV approach needed less lateral release (RR, 0.37; 95 % CI, 0.17-0.81; P = 0.01) and offered earlier straight leg raise (95 % CI, -3.11 to -0.69; P < 0.01) and superior knee flexion within 1 week postoperation (95 % CI, 1.96-8.20; P < 0.01) with no increase in the duration of surgery.

CONCLUSIONS

The preliminary results can be concluded that SV approach may provide an alternative to the MP approach with earlier rehabilitation and decreased lateral release rates in primary TKA; however, more high-quality randomized controlled trials should be designed to assess the medium and long-term outcomes between these two approaches.

LEVEL OF EVIDENCE

II.

Total shoulder arthroplasty versus hemiarthroplasty in patients with shoulder osteoarthritis: a meta-analysis of randomized controlled trials

OBJECTIVES

Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are treatment choices for end-stage shoulder osteoarthritis. The decision of whether to use TSA or HA is controversial. The objective of this study was to compare the effects of TSA and HA for shoulder osteoarthritis.

METHODS

We conducted a search for clinical studies that had been published in any language in December 2012 or before. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and several other databases. Randomized and quasi-randomized controlled clinical studies that evaluated different methods were included. At least two review authors independently performed the study selection, data collection, and data extraction. The software Revman 5.1 was used for the statistical analysis.

RESULTS

This study included 4 clinical trials. Two of the trials were published clinical trials, and the other 2 clinical trials were presented as unpublished abstracts. A total of 146 patients with 153 shoulders were included in the trials. Compared with HA, TSA presents with a higher UCLA shoulder scale (MD 3.10, 95% CI 1.13-5.08) and a higher ASES (MD 10.17, 95% CI 1.40-18.87). There was no significant difference between TSA and HA for revision (RR 0.35, 95% CI 0.10-1.19), WOOS (MD 9.10, 95% CI -2.72 to 20.92), and incidence of instability (RR 0.88, 95% CI 0.19-3.98). HA had a lower operation time (MD 39.00, 95% CI 17.05-60.95).

CONCLUSION

The available evidence suggests that TSA is more effective than HA for patients with shoulder arthritis.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Use of randomisation in clinical trials: a survey of UK practice

BACKGROUND

In healthcare research the randomised controlled trial is seen as the gold standard because it ensures selection bias is minimised. However, there is uncertainty as to which is the most preferred method of randomisation in any given setting and to what extent more complex methods are actually being implemented in the field.

METHODS

In this paper we describe the results of a survey of UK academics and publicly funded researchers to examine the extent of the use of various methods of randomisation in clinical trials.

RESULTS

Trialists reported using simple randomisation, permuted blocks and stratification more often than more complex methods such as minimisation. Most trialists believed that simple randomisation is suitable for larger trials but there is a high probability of possible imbalance between treatment groups in small trials. It was thought that groups should be balanced at baseline to avoid imbalance and help face-validity. However, very few respondents considered that more complex methods offer any advantages.

CONCLUSIONS

This paper demonstrates that for most UK trialists the preferred method of randomisation is using permuted blocks of varying random length within strata. This method eliminates the problem of predictability while maintaining balance across combinations of factors. If the number of prognostic factors is large, then minimisation can be used to provide treatment balance as well as balance over these factors. However, only those factors known to affect outcome should be considered.

Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review

INTRODUCTION

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.

METHODS

Cochrane Central Register of Controlled Trials (October 2010), PubMed (October 2010) and EMBASE (October 2010) were searched. Randomized and quasi-randomized controlled clinical trials were included. After independent study selection by two authors, data were collected and extracted independently. The methodological quality of the studies was assessed. Pooling of data was undertaken where appropriate.

RESULTS

Seven trials with 952 patients (965 fractures) were included. Compared with unreamed nailing, reamed nailing was significantly lower reoperation rate (RR 0.25, 95% CI 0.11-0.59, P = 0.002), lower non-union rate (RR 0.20, 95% CI 0.05-0.77, P = 0.02) and lower delay union rate(RR 0.30, 95% CI 0.14-0.64, P = 0.002). There was no significant difference when comparing reamed nailing with unreamed nailing for implant failure (RR 0.51, 95% CI 0.16-1.61, P = 0.25), mortality(RR 0.94, 95% CI 0.19-4.58, P = 0.94) and acute respiratory distress syndrome(RR 1.53, 95% CI 0.37-6.29, P = 0.55). Unreamed nailing was significantly less blood loss (SMD 119.23, 95% CI 59.04-180.43, P = 0.0001).

CONCLUSION

Reamed intramedullary nailing has better treatment effects than unreamed intramedullary nailing for shaft fracture of femur in adults.

How the psychosocial context of clinical trials differs from usual care: a qualitative study of acupuncture patients

Background

Qualitative studies of participants' experiences in randomised clinical trials (RCTs) suggest that the psychosocial context of treatment in RCTs may be quite different to the psychosocial context of treatment in usual practice. This is important, as the psychosocial context of treatment is known to influence patient outcomes in chronic illness. Few studies have directly compared the psychosocial context of treatment across RCTs and usual practice. In this study, we explored differences in psychosocial context between RCT and usual practice settings, using acupuncture as our model.

Methods

We undertook a secondary analysis of existing qualitative interviews with 54 patients. 27 were drawn from a study of western and traditional acupuncture in usual practice (for a range of painful conditions). 27 were drawn from a qualitative study nested in an RCT of western acupuncture for osteoarthritis of the hip or knee. We used qualitative analysis software to facilitate an inductive thematic analysis in which we identified three main themes.

Results

In usual practice, starting acupuncture was more likely to be embedded in an active and ongoing search for pain relief, whereas in the RCT starting acupuncture was opportunistic. Usual practice patients reported few uncertainties and these had minimal consequences for them. In the RCT, patients experienced considerable uncertainties about their treatment and its effectiveness, and were particularly concerned about whether they were receiving real (or fake) acupuncture. Patients stopped acupuncture only at the end of the fixed course of treatment in the RCT, which was similar to those receiving acupuncture in the public sector National Health Service (NHS). In comparison, private sector patients re-evaluated and re-negotiated treatments particularly when starting to use acupuncture.

Conclusions

Differences in psychosocial context between RCTs and usual practice could reduce the impact of acupuncture in RCT settings and/or lead to under-reporting of benefit by patients in trials. New trial designs that ensure participants' experiences are similar to usual practice should minimise differences in psychosocial context and help attenuate these potentially confounding effects.

A comparison of space closure rates between preactivated nickel-titanium and titanium-molybdenum alloy T-loops: a randomized controlled clinical trial

The purpose of this study was to conduct a prospective randomized controlled clinical trial to evaluate the rate of space closure and tooth angulation during maxillary canine retraction using preactivated T-loops made from titanium-molybdenum alloy (TMA) and nickel-titanium (NiTi). Twelve patients (six males and six females) aged between 13 and 20 years who had upper premolar extractions were included, and each acted as their own control, with a NiTi T-loop allocated to one quadrant and TMA to the other using a split mouth block randomization design. The loops were activated 3 mm at each visit to deliver a load of approximately 150 g to the upper canine teeth. Maxillary dental casts, taken at the first and each subsequent monthly visit, were used to evaluate changes in extraction space and canine angulation. All used T-loops were compared with unused loops in order to assess distortion. Mixed model statistical analysis was used to adjust for confounding variables. The mean rate of canine retraction using preactivated NiTi and TMA T-loops was 0.91 mm/month (±0.46) and 0.87 mm/month (±0.34), respectively. The canine tipping rates were 0.71 degrees/month (±2.34) for NiTi and 1.15 degrees/month (±2.86) for TMA. Both the rate of space closure and the tipping were not significantly different between the two wire types. The average percentage distortion of the TMA T-loop was 10 times greater than that of the NiTi loops when all other variables were matched. There was no difference in the rate of space closure or tooth angulation between preactivated TMA or NiTi T-loops when used to retract upper canines. The NiTi loops possessed a greater ability to retain and return to their original shapes following cyclical activation.

Generalized method for adaptive randomization in clinical trials

A flexible, generalized method of treatment allocation is proposed. The method uses a set of controlling parameters that enables the generic algorithm to produce a family of possible outcomes ranging from simple randomization to deterministic allocation. The method controls balance at stratum level, stratification level and overall without detriment to the predictability of the method. The paper lists the desirable characteristics of allocation methods and shows that the proposed method fulfils the majority and is easy to use in the clinical context, once the coding has been established. An explanation of the method for 2, 3 and 4 treatment group allocations is given. Simulations demonstrate the flexibility of the method.

A proposed taxonomy of terms to guide the clinical trial recruitment process

CONTEXT

The successful conduct of clinical trials in palliative care is challenged by low accrual rates, high attrition of study patients during trials, difficulties managing comorbidity, and other factors. But what has been learned about improving the feasibility of palliative care research studies?

OBJECTIVE

To develop standard terms to describe patient accrual, and using these terms, describe an approach to allow investigators to predict trial feasibility.

METHODS

We proposed a standard language and definitions for specific elements of feasibility within clinical trial design and conduct. We then developed an approach to apply data generated from the use of these terms to allow researchers to predict feasibility at the design stage of a clinical trial's development.

RESULTS

We developed a taxonomy and then retrospectively applied the approach to four trials selected from our library of completed studies, to provide preliminary validity evidence. The approach includes a framework to help predict the number of patients needed to be assessed to achieve a study's accrual targets, as part of ongoing operational oversight to monitor the conduct and feasibility of a clinical trial.

CONCLUSION

Challenges to successful completion of palliative care trials are prevalent and serious. A taxonomy to characterize the eligible patient pool, and an approach by which feasibility is systematically investigated, hold the promise to enhance the effectiveness of scarce resources applied to palliative and end-of-life research.

Normal Movement and Functional Approaches to Rehabilitate Lower Limb Dressing following Stroke: A Pilot Randomised Controlled Trial

Dressing difficulties are common following stroke. However, specific interventions lack evidence. This pilot single-blind randomised controlled trial investigated normal movement and functional approaches to rehabilitate lower limb dressing, given to four eligible stroke inpatients. The Nottingham Stroke Dressing Assessment, Rivermead Motor Assessment and Canadian Occupational Performance Measure were taken at baseline, discharge and 8 weeks. The small sample lacked power. Preliminary results indicated that while all patients improved with occupational therapy, approaches may differ in rates of motor recovery, independence and treatment duration. A total sample of 30 is required for more conclusive research to inform lower limb dressing interventions.

Interventions for preventing hamstring injuries

BACKGROUND

Some sports, such as football, have a high incidence of hamstring injuries. Various interventions targeting the prevention of such injuries are in common use.

OBJECTIVES

To assess the effects (primarily, on the incidence of hamstring injuries) of interventions used for preventing hamstring injuries in physically active individuals.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2008, Issue 4), MEDLINE and other databases (to December 2008), reference lists and clinical trials registers.

SELECTION CRITERIA

Randomised or quasi-randomised trials of interventions for preventing hamstring injuries were included; as were trials testing interventions for the prevention of lower-limb injuries, provided that hamstring injuries were reported. Secondary outcomes included compliance, severity and the occurrence of other leg injuries.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results, assessed methodological quality and extracted data. Risk ratios (RR) and 95% confidence intervals (95% CI) were calculated for dichotomous variables and are reported for individual and pooled data.

MAIN RESULTS

Seven randomised controlled trials involving 1919 participants were included. All trials involved people, predominantly young adults, participating in regular sporting activities. Some trials were compromised by poor methodology, including lack of blinding and incomplete outcome data.Four trials, including 287 participants, examined interventions directly targeted at preventing hamstring injuries. Three of these trials, which tested hamstring strengthening protocols, had contradictory findings, with one small trial showing benefit (although the control rate of mainly minor hamstring injury was unusually high). The other two trials found no benefit, with a greater incidence of hamstring injury in the intervention group. One unpublished and underpowered trial provided some evidence that manual therapy may prevent lower-limb muscle strain (RR 0.13, 95% CI 0.02 to 0.97), although the finding for hamstring injury did not reach statistical significance (RR 0.21, 95% CI 0.03 to 1.66).Three trials testing interventions for preventing lower limb injuries for which data for hamstring injury were available found no statistically significant effect for hamstring injury for either proprioceptive protocols (two cluster randomised trials) or a warm up/cool down and stretching protocol (one trial).

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to draw conclusions on the effectiveness of interventions used to prevent hamstring injuries in people participating in football or other high risk activities for these injuries. The findings for manual therapy need confirmation.

Is short-term palliative care cost-effective in multiple sclerosis? A randomized phase II trial

CONTEXT

Palliative care is being advocated for noncancer patients but needs evidence of effectiveness and cost-effectiveness.

OBJECTIVE

We evaluated the cost-effectiveness of a new palliative care service for people with multiple sclerosis (MS).

METHODS

We used a randomized fast-track Phase II controlled trial. Patients in South East London who were severely affected by MS were referred by clinicians to the trial. After baseline interview, patients were randomly allocated to either a multiprofessional palliative care team (PCT) immediately (fast track) or the control care group who continued best usual care for three months and then were offered the PCT. Data were collected at baseline, 6, 12, 18, and 26 weeks on use of services, patient symptoms, other outcomes, and caregiver burden.

RESULTS

Fifty-two patients were randomized: 25 fast track and 21 control patients completed the trial. There was a high level of disability, and mean Expanded Disability Status Scale score was 7.7 (median 8, standard deviation 1.0). At 12 weeks, caregiver burden was 4.47 points lower (95% confidence interval [CI]: 1.05-7.89) in the fast track compared to the control group. Mean service costs, including inpatient care and informal care, over the 0-12-week follow-up were pound1,789 lower for the fast-track group (bootstrapped 95% CI: - pound5,224 to pound1,902). There was a trend toward lower community costs in the fast-track group and no differences in costs to informal caregivers.

CONCLUSIONS

The trial suggests that short-term palliative care for people severely affected by MS and their caregivers will be cost-effective and warrants further study. The fast-track trial design could be used to assess this.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies.

OBJECTIVES

To compare the effectiveness of rehabilitation interventions following ankle fracture in adults.

SEARCH STRATEGY

We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

AUTHORS' CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Randomization procedures in orthopaedic trials

Historically, the surgical literature has lacked in reports of randomized clinical trials. This deficit is now being addressed, but the best methods are not always followed. One opportunity for improvement is in the area of randomization. Randomization is of central importance in clinical trials because it reduces bias and represents a basis for ensuring the validity of data analysis using statistical testing. Randomization requires a table of random numbers. Simple randomization is adequate for large trials. Block randomization is a method of balancing equal numbers of patients in each treatment group. Stratification allows balanced distribution of one or more confounding prognostic variables among treatment groups to ensure that groups have similar prognoses (minimizing selection bias). Block randomization and stratification improve validity in trials with fewer patients. Commercially available computer software facilitates randomization.

Randomised controlled trial of a new palliative care service: Compliance, recruitment and completeness of follow-up

Background

Palliative care has been proposed for progressive non-cancer conditions but there have been few evaluations of service developments. We analysed recruitment, compliance and follow-up data of a fast track (or wait list control) randomised controlled trial of a new palliative care service – a design not previously used to assess palliative care.

Methods/Design

An innovative palliative care service (comprising a consultant in palliative medicine, a clinical nurse specialist, an administrator and a psychosocial worker) was delivered to people severely affected by multiple sclerosis (MS), and their carers, in southeast London. Our design followed the MRC Framework for the Evaluation of Complex Interventions. In phase II we conducted randomised controlled trial, of immediate referral to the service (fast-track) versus a 12-week wait (standard best practice). Main outcome measures were: compliance (the extent the trial protocol was adhered to), recruitment (target 50 patients), attrition and missing data rates; trial outcomes were Palliative Care Outcome Scale and MS Impact Scale.

Results

69 patients were referred, 52 entered the trial (26 randomised to each arm), 5 refused consent and 12 were excluded from the trial for other reasons, usually illness or urgent needs, achieving our target numbers. 25/26 fast track and 21/26 standard best practice patients completed the trial, resulting in 217/225 (96%) of possible interviews completed, 87% of which took place in the patient's home. Main reasons for failure to interview and/or attrition were death or illness. There were three deaths in the standard best practice group and one in the fast-track group during the trial. At baseline there were no differences between groups. Missing data for individual questionnaire items were small (median 0, mean 1–5 items out of 56+ items per interview), not associated with any patient or carer characteristics or with individual questionnaires, but were associated with interviewer.

Conclusion

This is the first time a fast track (or wait list) randomised trial has been reported in palliative care. We found it achieved good recruitment and is a feasible method to evaluate palliative care services when patients are expected to live longer than 3–6 months. Home interviews are needed for a trial of this kind; interviewers need careful recruitment, training and supervision; and there should be careful separation from the clinical service of the control patients to prevent accidental contamination.

Trial Registration

Clinical Trials.Gov NCT00364963

Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up

A randomised clinical trial in primary care with a 12-months follow-up period. About 135 patients with acute sciatica (recruited from May 2003 to November 2004) were randomised in two groups: (1) the intervention group received physical therapy (PT) added to the general practitioners’ care, and (2) the control group with general practitioners’ care only. To assess the effectiveness of PT additional to general practitioners’ care compared to general practitioners’ care alone, in patients with acute sciatica. There is a lack of knowledge concerning the effectiveness of PT in patients with sciatica. The primary outcome was patients’ global perceived effect (GPE). Secondary outcomes were severity of leg and back pain, severity of disability, general health and absence from work. The outcomes were measured at 3, 6, 12 and 52 weeks after randomisation. At 3 months follow-up, 70% of the intervention group and 62% of the control group reported improvement (RR 1.1; 95% CI 0.9–1.5). At 12 months follow-up, 79% of the intervention group and 56% of the control group reported improvement (RR 1.4; 95% CI 1.1; 1.8). No significant differences regarding leg pain, functional status, fear of movement and health status were found at short-term or long-term follow-up. At 12 months follow-up, evidence was found that PT added to general practitioners’ care is only more effective regarding GPE, and not more cost-effective in the treatment of patients with acute sciatica than general practitioners’ care alone. There are indications that PT is especially effective regarding GPE in patients reporting severe disability at presentation.

Cost-effectiveness of physical therapy and general practitioner care for sciatica

STUDY DESIGN

An economic evaluation alongside a randomized clinical trial in primary care. A total of 135 patients were randomly allocated to physical therapy added to general practitioners' care (n = 67) or to general practitioners' care alone (n = 68).

OBJECTIVE

To evaluate the cost-effectiveness of physical therapy and general practitioner care for patients with an acute lumbosacral radicular syndrome (LRS, also called sciatica) compared with general practitioner care only.

SUMMARY OF BACKGROUND DATA

There is a lack of knowledge concerning the cost-effectiveness of physical therapy in patients with sciatica.

METHODS

The clinical outcomes were global perceived effect and quality of life. The direct and indirect costs were measured by means of questionnaires. The follow-up period was 1 year. The Incremental Cost-effectiveness Ratio (ICER) between both study arms was constructed. Confidence intervals for the ICER were calculated using Fieller's method and using bootstrapping.

RESULTS

There was a significant difference on perceived recovery at 1-year follow-up in favor of the physical therapy group. The additional physical therapy did not have an incremental effect on quality of life. At 1-year follow-up, the ICER for the total costs was 6224 euros (95% confidence interval, -10,419, 27,551) per improved patient gained. For direct costs only, the ICER was 837 euros (95% confidence interval, -731, 3186).

CONCLUSION

The treatment of patients with LRS with physical therapy and general practitioners'care is not more cost-effective than general practitioners'care alone.

Can face-to-face patient education be replaced by computer-based patient education? A randomised trial

OBJECTIVE

Computer-based patient education is an effective (therapeutic) tool. More and more studies prove that it can be an effective additive for face-to-face education, but it is still unclear if it is possible to educate patients by only using a computer. Our objective was to compare knowledge levels and satisfaction scores after computer-based patient education versus doctor-based patient education.

METHODS

We started a randomised and stratified trial in a large plastic surgery clinic in the Netherlands. One hundred thirteen patients with carpal tunnel syndrome (CTS), scheduled for operation were included. One group received CTS education by a doctor using a checklist (group A). The other group received the same CTS education by specially designed interactive computer program (group B). After 2 weeks, knowledge levels and satisfaction scores were tested by using a questionnaire.

RESULTS

One hundred thirteen patients were included, 96 patients finished the questionnaire. With respect to knowledge levels the doctor group (A) scored 20.2 points (max 40 points), and the computer group (B) scored 23.5 points. After correction the difference was 2.8 points (p=0.001). The total satisfaction score in group A was 7.6 and in group B 7.5; a difference of -0.16 (p=0.585).

CONCLUSIONS

The results suggest that educating patients can result in a higher knowledge levels by using a computer than by using a doctor. Satisfaction seems equal after both methods of education.

PRACTICE IMPLICATIONS

Knowing that you can educate patients without seeing a doctor or nurse seems promising. Patient can be educated by computer-based education programs leaving more time in a consultation for asking questions and discussing treatment options. The discussion will be at a more equal level of knowledge. Possibly it can save time and money resulting in a more efficient patient care, without dissatisfying our patients.

Brief smoking cessation advice from practice nurses during routine cervical smear tests appointments: a cluster randomised controlled trial assessing feasibility, acceptability and potential effectiveness

The aim of this study is to assess the potential effectiveness, acceptability and feasibility of a brief smoking cessation intervention delivered as part of cervical screening. A cluster randomised controlled trial was conducted with clinic week as the unit of randomisation, comparing a group (n=121) receiving brief smoking cessation advice supplemented with written information given by practice nurses during cervical smear test appointments, with a group (n=121) not receiving this advice. Outcomes were intention to stop smoking (potential effectiveness); intention to attend for future cervical screening (acceptability); duration of intervention (feasibility). 172/242 (71%) and 153/242 (63%) participants completed 2-week and 10-week follow-ups, respectively. Compared to women in the control group, those in the intervention group had higher intentions to stop smoking at 2-weeks (adjusted mean difference 0.51, 95% CI: -0.02 to 1.03, P=0.06) and 10-weeks (adjusted mean difference 0.80, 95% CI 0.10 to 1.50, P=0.03). The two groups had similarly high intentions to attend for future screening. Consultations in the intervention arm took a mean of 4.98 min (95% CI: 3.69 to 6.27; P<0.001) longer than the control arm. In conclusion, brief smoking cessation advice given by practice nurses as part of cervical screening seems acceptable, feasible and potentially effective. Evidence is lacking on the effectiveness and cost effectiveness of this intervention in achieving biochemically validated smoking cessation.