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Maiga AW, Snyder RA, Kao LS, Raval MV, Patel MB, Blakely ML. Advancing Randomized Clinical Trials in Surgery: Role of Exception From Informed Consent, Central Institutional Review Board, and Bayesian Approaches. J Surg Res 2024:S0022-4804(24)00167-7. [PMID: 38670847 DOI: 10.1016/j.jss.2024.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/16/2024] [Accepted: 03/12/2024] [Indexed: 04/28/2024]
Affiliation(s)
- Amelia W Maiga
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Rebecca A Snyder
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mayur B Patel
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research Education and Clinical Center, Surgical Services, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Martin L Blakely
- Department of Surgery, Institute for Clinical Research and Learning Health Care, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, Texas
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Natarajan P, Menounos S, Harris L, Monuja M, Gorelik A, Karjalainen T, Buchbinder R, Harris IA, Naylor JM, Adie S. Participant recruitment and attrition in surgical randomised trials with placebo controls versus non-operative controls: a meta-epidemiological study and meta-analysis. BMJ Open 2024; 14:e080258. [PMID: 38637129 PMCID: PMC11029374 DOI: 10.1136/bmjopen-2023-080258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/22/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVE To compare differences in recruitment and attrition between placebo control randomised trials of surgery, and trials of the same surgical interventions and conditions that used non-operative (non-placebo) controls. DESIGN Meta-epidemiological study. DATA SOURCES Randomised controlled trials were identified from an electronic search of MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from their inception date to 21 November 2018. STUDY SELECTION Placebo control trials evaluating efficacy of any surgical intervention and non-operative control trials of the same surgical intervention were included in this study. 25 730 records were retrieved from our systemic search, identifying 61 placebo control and 38 non-operative control trials for inclusion in analysis. OUTCOME MEASURES Primary outcome measures were recruitment and attrition. These were assessed in terms of recruitment rate (number of participants enrolled, as a proportion of those eligible) and overall attrition rate (composite of dropout, loss to follow-up and cross-overs, expressed as proportion of total sample size). Secondary outcome measures included participant cross-over rate, dropout and loss to follow-up. RESULTS Unadjusted pooled recruitment and attrition rates were similar between placebo and non-operative control trials. Study characteristics were not significantly different apart from time to primary timepoint which was shorter in studies with placebo controls (365 vs 274 days, p=0.006). After adjusting for covariates (follow-up duration and number of timepoints), the attrition rate of placebo control trials was almost twice as high compared with non-operative controlled-trials (incident rate ratio (IRR) (95% CI) 1.8 (1.1 to 3.0), p=0.032). The incorporation of one additional follow-up timepoint (regardless of follow-up duration) was associated with reduced attrition in placebo control surgical trials (IRR (95% CI) 0.64 (0.52 to 0.79), p<0.001). CONCLUSIONS Placebo control trials of surgery have similar recruitment issues but higher attrition compared with non-operative (non-placebo) control trials. Study design should incorporate strategies such as increased timepoints for given follow-up duration to mitigate losses to follow-up and dropout. PROSPERO REGISTRATION NUMBER CRD42019117364.
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Affiliation(s)
- Pragadesh Natarajan
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Spiro Menounos
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Laura Harris
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| | - Masiath Monuja
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Teemu Karjalainen
- Department of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Justine M Naylor
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Sam Adie
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
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Ho EKY, Mobbs RJ, van Gelder JM, Harris IA, Davis G, Stanford R, Beard DJ, Maher CG, Prior J, Knox M, Anderson DB, Buchbinder R, Ferreira ML. Challenges of conducting a randomised placebo-controlled trial of spinal surgery: the SUcceSS trial of lumbar spine decompression. Trials 2023; 24:794. [PMID: 38057932 PMCID: PMC10698887 DOI: 10.1186/s13063-023-07772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/01/2023] [Indexed: 12/08/2023] Open
Abstract
Although placebo-controlled trials are considered the gold standard for evaluating the efficacy of healthcare interventions, they can be perceived to be controversial and challenging to conduct for surgical treatments. The SUcceSS trial is the first placebo-controlled trial of lumbar decompression surgery for symptomatic lumbar canal stenosis. The SUcceSS trial has experienced common issues affecting the implementation of randomised placebo-controlled surgery trials, accentuated by the COVID-19 pandemic. Using the SUcceSS trial as an example, we discuss key challenges and mitigation strategies specific to the conduct of a randomised placebo-controlled surgical trial. Overall, the key lessons learned were (i) involving key stakeholders early and throughout the trial design phase may increase clinician and patient willingness to participate in a placebo-controlled trial of surgical interventions, (ii) additional resources (e.g. budget, staff time) are likely required to successfully operationalise trials of this nature, (iii) the level of placebo fidelity, timing of randomisation relative to intervention delivery, and nuances of the surgical procedure under investigation should be considered carefully. Findings are based on one example of a placebo-controlled surgical trial; however, researchers may benefit from employing or building from the strategies described and lessons learned when designing or implementing future trials of this nature.
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Affiliation(s)
- Emma Kwan-Yee Ho
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, Sydney, NSW, 2050, Australia.
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - Ralph Jasper Mobbs
- NeuroSpine Surgery Reserach Group (NSURG), Sydney, NSW, 2031, Australia
- Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - James Montague van Gelder
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Sydney Spine Institute, Burwood, NSW, 2134, Australia
| | - Ian Andrew Harris
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW, 2170, Australia
| | - Gavin Davis
- Neurosurgery, Cabrini & Austin Hospitals; and School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3800, Australia
| | - Ralph Stanford
- Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
| | - David John Beard
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, Sydney, NSW, 2050, Australia
- NHMRC CTC, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Joanna Prior
- The University of Sydney, School of Health Sciences, Faculty of Medicine and Health, Sydney, NSW, 2050, Australia
| | - Michael Knox
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - David Barrett Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3800, Australia
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Manuela Loureiro Ferreira
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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Cousins S, Gormley A, Chalmers K, Campbell MK, Beard DJ, Blencowe NS, Blazeby JM. How do pilot and feasibility studies inform randomised placebo-controlled trials in surgery? A systematic review. BMJ Open 2023; 13:e071094. [PMID: 37989384 PMCID: PMC10660967 DOI: 10.1136/bmjopen-2022-071094] [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: 12/16/2022] [Accepted: 09/28/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) with a placebo comparator are considered the gold standard study design when evaluating healthcare interventions. These are challenging to design and deliver in surgery. Guidance recommends pilot and feasibility work to optimise main trial design and conduct; however, the extent to which this occurs in surgery is unknown. METHOD A systematic review identified randomised placebo-controlled surgical trials. Articles published from database inception to 31 December 2020 were retrieved from Ovid-MEDLINE, Ovid-EMBASE and CENTRAL electronic databases, hand-searching and expert knowledge. Pilot/feasibility work conducted prior to the RCTs was then identified from examining citations and reference lists. Where studies explicitly stated their intent to inform the design and/or conduct of the future main placebo-controlled surgical trial, they were included. Publication type, clinical area, treatment intervention, number of centres, sample size, comparators, aims and text about the invasive placebo intervention were extracted. RESULTS From 131 placebo surgical RCTs included in the systematic review, 47 potentially eligible pilot/feasibility studies were identified. Of these, four were included as true pilot/feasibility work. Three were original articles, one a conference abstract; three were conducted in orthopaedic surgery and one in oral and maxillofacial surgery. All four included pilot RCTs, with an invasive surgical placebo intervention, randomising 9-49 participants in 1 or 2 centres. They explored the acceptability of recruitment and the invasive placebo intervention to patients and trial personnel, and whether blinding was possible. One study examined the characteristics of the proposed invasive placebo intervention using in-depth interviews. CONCLUSION Published studies reporting feasibility/pilot work undertaken to inform main placebo surgical trials are scarce. In view of the difficulties of undertaking placebo surgical trials, it is recommended that pilot/feasibility studies are conducted, and more are reported to share key findings and optimise the design of main RCTs. PROSPERO REGISTRATION NUMBER CRD42021287371.
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Affiliation(s)
- Sian Cousins
- Surgical Innovation theme, Bristol National Institute for Health and Care Research (NIHR) Biomedical Research Centre; Royal College of Surgeons of England (RCSEng) Bristol Surgical Trials Centre, Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Katy Chalmers
- Surgical Innovation theme, Bristol National Institute for Health and Care Research (NIHR) Biomedical Research Centre; Royal College of Surgeons of England (RCSEng) Bristol Surgical Trials Centre, Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marion K Campbell
- Royal College of Surgeons of England, Aberdeen Surgical Trials Centre; Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; RCSEng Surgical Intervention Trials Unit; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Natalie S Blencowe
- Surgical Innovation theme, Bristol National Institute for Health and Care Research (NIHR) Biomedical Research Centre; Royal College of Surgeons of England (RCSEng) Bristol Surgical Trials Centre, Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Surgical Innovation theme, Bristol National Institute for Health and Care Research (NIHR) Biomedical Research Centre; Royal College of Surgeons of England (RCSEng) Bristol Surgical Trials Centre, Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Ninomiya MM, Hiemstra J, Nicholson E, Isaac KV. Methods of Recruitment for Surgical and Perioperative Randomized Controlled Trials: A Rapid Review. World J Surg 2023; 47:2659-2667. [PMID: 37589794 DOI: 10.1007/s00268-023-07124-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/18/2023]
Abstract
Due to the complex nature of surgical randomized controlled trials (RCTs), reaching target recruitment can be challenging. The primary objective was to report on characteristics of successful pilot surgical and perioperative RCTs and the methodological strategies implemented to optimize recruitment. The secondary objective was to provide recommendations for successful recruitment strategies for future surgical RCTs. Ovid MEDLINE, Ovid EMBASE, and Web of Science (via Ovid) databases were searched from 2012 to 2022. This review included surgical and perioperative pilot studies that met their recruitment targets. Study and recruitment characteristics were summarized, and potential relationships between study design and recruitment rate were assessed. Optimized recruitment strategies were extracted when reported. Of 4156 total articles identified, 255 underwent full-text screening, and 52 articles were included. Of the included pilot studies, 21% (n = 11) did not indicate a target sample size or recruitment rate. Recruitment methods were minimally reported in pilot studies for perioperative or surgical RCTs. Strategies to optimize recruitment included internal iterative evaluations of the recorded recruitment appointments and staged introduction of the study. Recruitment rate was not associated with invasiveness of intervention or burden of participation. Patient involvement is absent from current reports on methodological design and offers valuable opportunity to optimize recruitment. Recruitment strategies in perioperative and surgical RCTs can be optimized with iterative qualitative evaluation of the recruitment methods with input from the interdisciplinary research team.
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Affiliation(s)
- Maya Morton Ninomiya
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Jenna Hiemstra
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Emma Nicholson
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, 2221 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Kathryn V Isaac
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, 2221 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
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Little MW, Harrison R, MacGill S, Speirs A, Briggs JH, Tayton E, Davies NLC, Hausen HS, McCann C, Levine LL, Sharma RA, Gibson M. Genicular Artery Embolisation in Patients with Osteoarthritis of the Knee (GENESIS 2): Protocol for a Double-Blind Randomised Sham-Controlled Trial. Cardiovasc Intervent Radiol 2023; 46:1276-1282. [PMID: 37337060 PMCID: PMC10471661 DOI: 10.1007/s00270-023-03477-z] [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: 03/30/2023] [Accepted: 05/23/2023] [Indexed: 06/21/2023]
Abstract
Knee osteoarthritis is a leading cause of chronic disability and economic burden. In many patients who are not surgical candidates, existing treatment options are insufficient. Clinical evidence for a new treatment approach, genicular artery embolisation (GAE), is currently limited to single arm cohort, or small population randomised studies. This trial will investigate the use of a permanent embolic agent for embolisation of abnormal genicular arterial vasculature to reduce pain in patients with mild to moderate knee osteoarthritis. Up to 110 participants, 45 years or older, with knee pain for ≥ 3 months resistant to conservative treatment will be randomised (1:1) to GAE or a sham procedure. The treatment group will receive embolisation using 100-micron Embozene™ microspheres (Varian, a Siemens Healthineers Company) (investigational use for this indication in the UK), and the sham group will receive 0.9% saline in an otherwise identical procedure. Patients will be followed for 24 months. At 6 months, sham participants will be offered crossover to GAE. The primary endpoint is change of 4 Knee Injury and OA Outcome Score subscales (KOOS4) at 6 months post-randomisation. The study will also evaluate quality of life, health economics, imaging findings, and psychosocial pain outcomes. The primary manuscript will be submitted for publication after all participants complete 6 months of follow-up. The trial is expected to run for 3.5 years. Trial Registration: ClinicalTrials.gov, Identifier: NCT05423587.
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Affiliation(s)
- Mark W Little
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK.
- Centre for Integrative Neuroscience and Neurodynamics, University of Reading, Reading, UK.
| | - Richard Harrison
- Centre for Integrative Neuroscience and Neurodynamics, University of Reading, Reading, UK
| | - Sarah MacGill
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - Archie Speirs
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - James H Briggs
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - Edward Tayton
- Department of Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Nev L C Davies
- Department of Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | | | - Claire McCann
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - Lisa L Levine
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | | | - Matthew Gibson
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
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Mackenzie SC, Stephen J, Williams L, Daniels J, Norrie J, Becker CM, Byrne D, Cheong Y, Clark TJ, Cooper KG, Cox E, Doust AM, Fernandez P, Hawe J, Holland T, Hummelshoj L, Jackson LJ, King K, Maheshwari A, Martin DC, Sutherland L, Thornton J, Vincent K, Vyas S, Horne AW, Whitaker LHR. Effectiveness of laparoscopic removal of isolated superficial peritoneal endometriosis for the management of chronic pelvic pain in women (ESPriT2): protocol for a multi-centre randomised controlled trial. Trials 2023; 24:425. [PMID: 37349849 PMCID: PMC10286505 DOI: 10.1186/s13063-023-07386-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: 04/21/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Endometriosis affects 190 million women and those assigned female at birth worldwide. For some, it is associated with debilitating chronic pelvic pain. Diagnosis of endometriosis is often achieved through diagnostic laparoscopy. However, when isolated superficial peritoneal endometriosis (SPE), the most common endometriosis subtype, is identified during laparoscopy, limited evidence exists to support the common decision to surgically remove it via excision or ablation. Improved understanding of the impact of surgical removal of isolated SPE for the management of chronic pelvic pain in women is required. Here, we describe our protocol for a multi-centre trial to determine the effectiveness of surgical removal of isolated SPE for the management of endometriosis-associated pain. METHODS We plan to undertake a multi-centre participant-blind parallel-group randomised controlled clinical and cost-effectiveness trial with internal pilot. We plan to randomise 400 participants from up to 70 National Health Service Hospitals in the UK. Participants with chronic pelvic pain awaiting diagnostic laparoscopy for suspected endometriosis will be consented by the clinical research team. If isolated SPE is identified at laparoscopy, and deep or ovarian endometriosis is not seen, participants will be randomised intraoperatively (1:1) to surgical removal (by excision or ablation or both, according to surgeons' preference) versus diagnostic laparoscopy alone. Randomisation with block-stratification will be used. Participants will be given a diagnosis but will not be informed of the procedure they received until 12 months post-randomisation, unless required. Post-operative medical treatment will be according to participants' preference. Participants will be asked to complete validated pain and quality of life questionnaires at 3, 6 and 12 months after randomisation. Our primary outcome is the pain domain of the Endometriosis Health Profile-30 (EHP-30), via a between randomised group comparison of adjusted means at 12 months. Assuming a standard deviation of 22 points around the pain score, 90% power, 5% significance and 20% missing data, 400 participants are required to be randomised to detect an 8-point pain score difference. DISCUSSION This trial aims to provide high quality evidence of the clinical and cost-effectiveness of surgical removal of isolated SPE. TRIAL REGISTRATION ISRCTN registry ISRCTN27244948. Registered 6 April 2021.
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Affiliation(s)
- Scott C Mackenzie
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Linda Williams
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Christian M Becker
- Endometriosis CaRe, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX3 9DU, UK
| | | | - Ying Cheong
- Faculty of Medicine, Human Development and Health, University of Southampton, Southampton, UK
| | - T Justin Clark
- Birmingham Women's and Children Hospital, Birmingham, B15 2TG, UK
| | - Kevin G Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
| | | | - Ann M Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Priscilla Fernandez
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jeremy Hawe
- Corniche Hospital, Abu Dhabi, United Arab Emirates
| | | | | | | | | | | | - Dan C Martin
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
- Virginia Commonwealth University, Institutional Review Board, Richmond, VA, USA
- EndoFound (Endometriosis Foundation of America), New York, USA
| | - Lauren Sutherland
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | | | - Katy Vincent
- Endometriosis CaRe, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX3 9DU, UK
| | - Sanjay Vyas
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK.
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Rebelo A, Klose J, Kleeff J, Ronellenfitsch U. Is it feasible and ethical to randomize patients between surgery and non-surgical treatments for gastrointestinal cancers? Front Oncol 2023; 13:1119436. [PMID: 37007103 PMCID: PMC10061124 DOI: 10.3389/fonc.2023.1119436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundIn several settings in the treatment of gastrointestinal cancers, it is unclear if the addition of surgery to a multimodal treatment strategy, or in some circumstances its omission, lead to a better outcome for patients. In such situations of clinical equipoise, high-quality evidence from randomised-controlled trials is needed to decide which treatment approach is preferable.ObjectiveIn this article, we outline the importance of randomised trials comparing surgery with non-surgical therapies for specific scenarios in the treatment of gastrointestinal cancers. We explain the difficulties and solutions of designing these trials and recruiting patients in this context.MethodsWe performed a selective review based on a not systematic literature search in core databases, supplemented by browsing health information journals and citation searching. Only articles in English were selected. Based on this search, we discuss the results and methodological characteristics of several trials which randomised patients with gastrointestinal cancers between surgery and non-surgical treatments, highlighting their differences, advantages, and limitations.Results and conclusionsInnovative and effective cancer treatment requires randomised trials, also comparing surgery and non-surgical treatments for defined scenarios in the treatment of gastrointestinal malignancies. Nevertheless, potential obstacles to designing and carrying out these trials must be recognised ahead of time to avoid problems before or during the trial.
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Marschall H, Forman A, Lunde SJ, Kesmodel US, Hansen KE, Vase L. Is laparoscopic excision for superficial peritoneal endometriosis helpful or harmful? Protocol for a double-blinded, randomised, placebo-controlled, three-armed surgical trial. BMJ Open 2022; 12:e062808. [PMID: 36328387 PMCID: PMC9639085 DOI: 10.1136/bmjopen-2022-062808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Placebo-controlled surgical designs are recommended to ascertain treatment effects for elective surgeries when there is genuine doubt about the effectiveness of the surgery. Some elective surgeries for pain have been unable to show an effect beyond sham surgery, suggesting contributions from contextual factors. However, the nature of contextual factors in elective surgery is largely unexplored. Further, methodological difficulties in placebo-controlled surgical trials impact the ability to estimate the effectiveness of a surgical procedure. These include an overall lack of testing the success of blinding, absence of comparison to a no-surgery control group and dearth of test for neuropathic pain.For women with peritoneal endometriosis, there is uncertainty regarding the pain-relieving effect of surgery. Surgery may put patients at risk of complications such as postsurgical neuropathic pain, without guarantees of sufficient pelvic pain relief. The planned placebo-controlled trial aims to examine the effect of surgery on pelvic pain, widespread pain and neuropathic pain symptoms in women with peritoneal endometriosis, and to test the contribution of contextual factors to pain relief. METHODS AND ANALYSIS One hundred women with peritoneal endometriosis will be randomised to either diagnostic laparoscopy with excision of endometrial tissue (active surgery), purely diagnostic laparoscopy (sham surgery) or delayed surgery (no-surgery control group). Outcomes include pelvic pain relief, widespread pain, neuropathic pain symptoms and quality of life. Contextual factors are also assessed. Assessments will be obtained at baseline and 1, 3 and 6 months postrandomisation. Mixed linear models will be used to compare groups over time on all outcome variables. ETHICS AND DISSEMINATION The trial is approved by the Regional Ethics Committee in the Central Denmark Region (1-10-72-152-20). The trial is funded by a PhD scholarship from Aarhus University, and supported by a grant from 'Helsefonden' (20-B-0448). Findings will be published in international peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER NCT05162794.
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Affiliation(s)
- Henrik Marschall
- School of Business and Social Sciences, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Axel Forman
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sigrid Juhl Lunde
- School of Business and Social Sciences, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Ulrik Schiøler Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Lene Vase
- School of Business and Social Sciences, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
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Funck-Brentano C. Evidence-based medicine: Friend and foe. Therapie 2022:S0040-5957(22)00143-3. [PMID: 36192190 DOI: 10.1016/j.therap.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/13/2022] [Indexed: 12/03/2022]
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Lie MLS, McParlin C, McColl E, Graham RH, Robson SC. Emesis in pregnancy - a qualitative study on trial recruitment failure from the EMPOWER internal pilot. Pilot Feasibility Stud 2022; 8:146. [PMID: 35836285 PMCID: PMC9281005 DOI: 10.1186/s40814-022-01093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As part of the internal pilot of the EMPOWER trial investigating the second-line antiemetic therapies in severe emesis in pregnancy ( https://www.isrctn.com/ISRCTN16924692 ), a qualitative study of women's views was carried out, to improve our understanding of why women did, or did not, consent to participation in the trial. Interviews were also conducted with site research staff, to broaden our analysis and explore other factors affecting recruitment. METHODS The sample comprised women who accepted or declined trial participation (n=21) and site research staff (n=22). A structured topic guide was used, in four email interviews and 17 telephone interviews with women, and semi-structured telephone interviews were carried out with staff. Of the women interviewed, seven had declined trial participation, and of the staff interviewed, 16 were research midwives/research nurses and six were principal investigators. All transcripts were checked for accuracy, anonymised and entered into NVIVO12 for indexing and retrieval. Data was analysed using a reflexive thematic analytic approach. In total, 72 codes were generated from the thematic analysis, and 36 from each sample group. RESULTS Three key themes based on all the interviews were (a) the diversity of recruitment pathways and boundaries of care, (b) the impact of trial complexity on recruitment and staff morale and (c) the ethics of caring for a patient with emesis. Ethical issues discussed included the use of double dummy and time to treat, particularly those suffering severely from the effects of nausea and vomiting. To illustrate these themes, staff perspectives are given more prominence. CONCLUSIONS The main reason the trial was stopped related to the high proportion of women ineligible for recruitment due to prior treatment with study drug(s) because of unanticipated changes in clinical practice. The qualitative results also demonstrate the impact of the trial on women and staff and highlight how the diversity of referral pathways, boundaries of care and the complexity of the trial and protocol resulted in additional barriers to successful trial recruitment. Qualitative work in pilot and feasibility studies of a clinical trial is recommended, to evaluate whether recruitment strategies remain viable in unanticipated contexts. TRIAL REGISTRATION Trial registration number ISRCTN16924692 . Date: 08/01/2018.
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A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy. J Pers Med 2022; 12:jpm12071065. [PMID: 35887562 PMCID: PMC9320410 DOI: 10.3390/jpm12071065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompression (ELD) and categorized into primary pain generators (PPG). Identifying these PPGs provides crucial information for a successful outcome with ELD and forms the basis for our proposed personalized spine care protocol (SpineScreen). Methods: a prospective study of 412 patients from 7 endoscopic practices consisting of 207 (50.2%) males and 205 (49.8%) females with an average age of 63.67 years and an average follow-up of 69.27 months was performed to compare the durability of targeted ELD based on validated primary pain generators versus image-based open lumbar laminectomy, and minimally invasive lumbar transforaminal interbody fusion (TLIF) using Kaplan-Meier median survival calculations. The serial time was determined as the interval between index surgery and when patients were censored for additional interventional and surgical treatments for low back-related symptoms. A control group was recruited from patients referred for a surgical consultation but declined interventional and surgical treatment and continued on medical care. Control group patients were censored when they crossed over into any surgical or interventional treatment group. Results: of the 412 study patients, 206 underwent ELD (50.0%), 61 laminectomy (14.8%), and 78 (18.9%) TLIF. There were 67 patients in the control group (16.3% of 412 patients). The most common surgical levels were L4/5 (41.3%), L5/S1 (25.0%), and L4-S1 (16.3%). At two-year f/u, excellent and good Macnab outcomes were reported by 346 of the 412 study patients (84.0%). The VAS leg pain score reduction was 4.250 ± 1.691 (p < 0.001). No other treatment during the available follow-up was required in 60.7% (125/206) of the ELD, 39.9% (31/78) of the TLIF, and 19.7% (12/61 of the laminectomy patients. In control patients, only 15 of the 67 (22.4%) control patients continued with conservative care until final follow-up, all of which had fair and poor functional Macnab outcomes. In patients with Excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients (p < 0.001). The overall survival time in control patients was eight months with a standard error of 0.942, a lower boundary of 6.154, and an upper boundary of 9.846 months. In patients with excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients versus control patients at seven months (p < 0.001). The most common new-onset symptom for censoring was dysesthesia ELD (9.4%; 20/206), axial back pain in TLIF (25.6%;20/78), and recurrent pain in laminectomy (65.6%; 40/61) patients (p < 0.001). Transforaminal epidural steroid injections were tried in 11.7% (24/206) of ELD, 23.1% (18/78) of TLIF, and 36.1% (22/61) of the laminectomy patients. The secondary fusion rate among ELD patients was 8.8% (18/206). Among TLIF patients, the most common additional treatments were revision fusion (19.2%; 15/78) and multilevel rhizotomy (10.3%; 8/78). Common follow-up procedures in laminectomy patients included revision laminectomy (16.4%; 10/61), revision ELD (11.5%; 7/61), and multilevel rhizotomy (11.5%; 7/61). Control patients crossed over into ELD (13.4%), TLIF (13.4%), laminectomy (10.4%) and interventional treatment (40.3%) arms at high rates. Most control patients treated with spinal injections (55.5%) had excellent and good functional outcomes versus 40.7% with fair and poor (3.7%), respectively. The control patients (93.3%) who remained in medical management without surgery or interventional care (14/67) had the worst functional outcomes and were rated as fair and poor. Conclusions: clinical outcomes were more favorable with lumbar surgeries than with non-surgical control groups. Of the control patients, the crossover rate into interventional and surgical care was 40.3% and 37.2%, respectively. There are longer symptom-free intervals after targeted ELD than with TLIF or laminectomy. Additional intervention and surgical treatments are more often needed to manage new-onset postoperative symptoms in TLIF- and laminectomy compared to ELD patients. Few ELD patients will require fusion in the future. Considering the rising cost of surgical spine care, we offer SpineScreen as a simplified and less costly alternative to traditional image-based care models by focusing on primary pain generators rather than image-based criteria derived from the preoperative lumbar MRI scan.
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Andreoletti M, Bina F. A defense of surgical procedures regulation. THEORETICAL MEDICINE AND BIOETHICS 2022; 43:155-168. [PMID: 35551584 PMCID: PMC9388414 DOI: 10.1007/s11017-022-09569-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 06/15/2023]
Abstract
Since the advent of drug regulation in 1962, regulatory agencies have been in the practice of using strict standards to test the safety and efficacy of medical treatments and products. Regulatory agencies, such as the FDA, demand two full-fledged Randomized Clinical Trials demonstrating the safety and effectiveness of drugs to grant its marketing authorization. On the contrary, surgical treatments are left completely unregulated. There are several reasons explaining this difference, and all of them point to the difficulty of conducting well-designed RCTs in surgery. However, we argue that none of these arguments is decisive and that, under certain conditions, surgical RCTs can be morally justified and methodologically sound. Although ethical constraints restrict the number of testable surgical procedures, and surgical trials might not be as dependable as pharmaceutical RCTs, our analysis suggests that, in certain cases, it is possible to obtain high-quality evidence about the safety and efficacy of surgical procedures. Untested surgical treatments may prove to be ineffective and harm patients. Therefore, regulation of surgical procedures seems not only morally acceptable and able to provide reliable scientific evidence, but also desirable and justified from an ethical-political standpoint.
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Affiliation(s)
- Mattia Andreoletti
- Health Ethics and Policy Lab, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Federico Bina
- Faculty of Philosophy, Vita-Salute San Raffaele University, Milan, Italy
- Department of Psychology, Harvard University, Cambridge, Massachusetts United States
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Ferraro MC, Gibson W, Rice ASC, Vase L, Coyle D, O'Connell NE. Spinal cord stimulation for chronic pain. Lancet Neurol 2022; 21:405. [DOI: 10.1016/s1474-4422(22)00096-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
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Kang YS, Bridgen A. First metatarsophalangeal joint arthrodesis/fusion: a systematic review of modern fixation techniques. J Foot Ankle Res 2022; 15:30. [PMID: 35468802 PMCID: PMC9040205 DOI: 10.1186/s13047-022-00540-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background First metatarsophalangeal joint arthrodesis is commonly performed for symptomatic end-stage hallux rigidus. It has been postulated to produce good results in the literature. Various fixation techniques offer differences in union rates, complications and functional outcomes, stirring debates about which produces the best outcomes for patients. Therefore, this review aims to synthesise and compare the outcomes of modern fixation techniques used for first metatarsophalangeal joint (FMPJ) arthrodesis. Methods The electronic database searched were PubMed, CINAHL, Cochrane Library, and Google Scholar. The critical appraisal skills programme tool for cohort study was used. The interventions consisted of screw(s), plate(s), and staple(s). Studies comprising outdated fixation techniques such as suture, metallic wire, external fixation, Rush rods or Steinmann pins were excluded. Participants were adults over 18 years, undergoing FMPJ arthrodesis in the UK. Studies with the population consisting primarily of revision cases, patients with rheumatoid arthritis or diabetes were excluded. Results Seven UK studies included 277 feet and a 95.7% overall union rate at a mean union time of 83.5 days. Staples had the highest union rate of 98.2% at mean union time of 84 days, followed by plates (95.2%, 92 days), and finally screws (94.9%, 71 days). The overall complication incidence is 5.8%. All of the fixation techniques produced good functional outcomes postoperatively. Conclusions Whilst staple techniques showed the highest union rate, plating techniques are preferable over screws or staples for better results across several outcome measures, including reduced complication incidence, stability, early ambulation, and good functional outcome. The Manchester-Oxford Foot Questionnaire and EuroQol-5Dimensional are recommended as measurement tools to assess functional outcomes following FMPJ arthrodesis. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00540-9.
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Affiliation(s)
- Yang S Kang
- Department of Podiatry, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK.
| | - Andy Bridgen
- Department of Podiatry, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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Hinwood M, Wall L, Lang D, Balogh ZJ, Smith A, Dowsey M, Clarke P, Choong P, Bunzli S, Paolucci F. Patient and clinician characteristics and preferences for increasing participation in placebo surgery trials: a scoping review of attributes to inform a discrete choice experiment. Trials 2022; 23:296. [PMID: 35413876 PMCID: PMC9006556 DOI: 10.1186/s13063-022-06277-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Orthopaedic surgeries include some of the highest volume surgical interventions globally; however, studies have shown that a significant proportion of patients report no clinically meaningful improvement in pain or function after certain procedures. As a result, there is increasing interest in conducting randomised placebo-controlled trials in orthopaedic surgery. However, these frequently fail to reach recruitment targets suggesting a need to improve trial design to encourage participation. The objective of this study was to systematically scope the available evidence on patient and clinician values and preferences which may influence the decision to participate in placebo surgery trial. Methods A systematic review was conducted via a literature search in the MEDLINE, Embase, PsycInfo, CINAHL, and EconLit databases as of 19 July 2021, for studies of any design (except commentaries or opinion pieces) based on two key concepts: patient and clinician characteristics, values and preferences, and placebo surgery trials. Results Of 3424 initial articles, we retained 18 eligible studies. Characteristics, preferences, values, and attitudes of patients (including levels of pain/function, risk/benefit perception, and altruism) and of clinicians (including concerns regarding patient deception associated with placebo, and experience/training in research) influenced their decisions to participate in placebo-controlled trials. Furthermore, some aspects of trial design, including randomisation procedures, availability of the procedure outside of the trial, and the information and consent procedures used, also influenced decisions to participate. Conclusion Participant recruitment is a significant challenge in placebo surgery trials, and individual decisions to participate appear to be sensitive to preferences around treatment. Understanding and quantifying the role patient and clinician preferences may play in surgical trials may contribute to the optimisation of the design and implementation of clinical trials in surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06277-x.
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Affiliation(s)
- Madeleine Hinwood
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia. .,Hunter Medical Research Institute, New Lambton Heights, Australia.
| | - Laura Wall
- Newcastle Business School, University of Newcastle, Newcastle, Australia
| | - Danielle Lang
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, Australia
| | - Angela Smith
- Hunter New England Local Health District, Newcastle, Australia
| | - Michelle Dowsey
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Phillip Clarke
- School of Population and Global Health, University of Melbourne, Australia, Parkville, Australia.,Health Economics Research Centre, University of Oxford, Oxford, England
| | - Peter Choong
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Samantha Bunzli
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Francesco Paolucci
- Newcastle Business School, University of Newcastle, Newcastle, Australia
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Anderson DB, Beard DJ, Sabet T, Eyles JP, Harris IA, Adie S, Buchbinder R, Maher CG, Ferreira ML. Evaluation of placebo fidelity and trial design methodology in placebo-controlled surgical trials of musculoskeletal conditions: a systematic review. Pain 2022; 163:637-651. [PMID: 34382608 DOI: 10.1097/j.pain.0000000000002432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The number of placebo surgical trials on musculoskeletal conditions is increasing, but little is known about the quality of their design and methods. This review aimed to (1) assess the level of placebo fidelity (ie, degree to which the placebo control mimicked the index procedure) in placebo trials of musculoskeletal surgery, (2) describe the trials' methodological features using the adapted Applying Surgical Placebo in Randomised Evaluations (ASPIRE) checklist, and (3) describe each trial's characteristics. We searched 4 electronic databases from inception until February 18, 2021, for randomised trials of surgery that included a placebo control for any musculoskeletal condition. Protocols and full text were used to assess placebo fidelity (categorised as minimal, low, or high fidelity). The adapted 26-item ASPIRE checklist was also completed on each trial. PROSPERO registration number: CRD42021202131. A total of 30,697 studies were identified in the search, and 22 placebo-controlled surgical trials of 2045 patients included. Thirteen trials (59%) included a high-fidelity placebo control, 7 (32%) used low fidelity, and 2 (9%) minimal fidelity. According to the ASPIRE checklist, included trials had good reporting of the "rationale and ethics" (68% overall) and "design" sections (42%), but few provided enough information on the "conduct" (13%) and "interpretation and translation" (11%) of the placebo trials. Most trials sufficiently reported their rationale and ethics, but interpretation and translation are areas for improvement, including greater stakeholder involvement. Most trials used a high-fidelity placebo procedure suggesting an emphasis on blinding and controlling for nonspecific effects.
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Affiliation(s)
- David B Anderson
- Faculty of Medicine and Health, School of Health Sciences, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, United Kingdom
| | - Tamer Sabet
- Department of Health Professionals, Faculty of Medicine, Health and Human Sciences, Macquarie University, New South Wales, Australia
| | - Jillian P Eyles
- Faculty of Medicine and Health, School of Medicine, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, UNSW Sydney, New South Wales, Australia Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney New South Wales, Australia
- St. George and Sutherland Clinical School, UNSW Sydney, New South Wales, Australia
| | - Sam Adie
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Rachelle Buchbinder
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Vic, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher G Maher
- St. George and Sutherland Clinical School, UNSW Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, School of Health Sciences, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
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Schnelle C, Clark J, Mascord R, Jones MA. Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review. Ther Clin Risk Manag 2022; 18:467-490. [PMID: 35502434 PMCID: PMC9056050 DOI: 10.2147/tcrm.s357934] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/04/2022] [Indexed: 12/23/2022] Open
Abstract
Objective To find and review published papers researching surgeons’ effects on patients’ physical health. Clinical outcomes of surgery patients with similar prognoses cannot be fully explained by surgeon skill or experience. Just as there are “hospital” and “psychotherapist” effects, there may be “surgeons” effects that persist after controlling for known variables like patient health and operation riskiness. Methods Cohort studies and randomized controlled trials (RCTs) of any surgical intervention, which, after multivariate adjustment, either showed proportion of variance in patients’ physical health outcomes due to surgeons (random effects) or graded surgeons from best to worst (fixed effects). Studies with <15 surgeons or only ascribing surgeons’ effects to known variables excluded. Medline, PubMed, Embase, and PsycINFO were used for search until June 2020. Manual search for papers referring/referred by resulting studies. Risk of bias assessed by Cochrane risk-of-bias tool and Newcastle–Ottawa Scale. Results Included studies: 52 cohort studies and three RCTs of 52,436+ surgeons covering 102 outcomes (33 unique). Studies either graded surgeons from best to worst or calculated the intra-class correlation coefficient (ICC), the percentage of patients’ variation due to surgeons, in diverse ways. Sixteen studies showed exceptionally good and/or bad performers with confidence intervals wholly above or below the average performance. ICCs ranged from 0 to 47%, median 4.0%. There are no well-established reporting standards; highly heterogeneous reporting, therefore no meta-analysis. Discussion Interpretation: There is a surgeons' effect on patients’ physical health for many types of surgeries and outcomes, ranging from small to substantial. Surgeons with exceptional patient outcomes appear regularly even after accounting for all known confounding variables. Many existing cohort studies and RCTs could be reanalyzed for surgeons’ effects especially after methodological reporting guidelines are published. Conclusion In terms of patient outcomes, it can matter which surgeon is chosen. Surgeons with exceptional patient outcomes are worth studying further. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/pL-eGyAGhSk
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Affiliation(s)
- Christoph Schnelle
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
- Correspondence: Christoph Schnelle, Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia, Email
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Rachel Mascord
- General Dentist, BMA House, Sydney, New South Wales, Australia
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
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Gaudino M, Chikwe J, Bagiella E, Bhatt DL, Doenst T, Fremes SE, Lawton J, Masterson Creber RM, Sade RM, Zwischenberger BA. Methodological Standards for the Design, Implementation, and Analysis of Randomized Trials in Cardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 145:e129-e142. [PMID: 34865513 DOI: 10.1161/cir.0000000000001037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac surgery presents specific methodological challenges in the design, implementation, and analysis of randomized controlled trials. The purposes of this scientific statement are to review key standards in cardiac surgery randomized trial design and implementation, and to provide recommendations for conducting and interpreting cardiac surgery trials. Recommendations include a careful evaluation of the suitability of the research question for a clinical trial, assessment of clinical equipoise, feasibility of enrolling a representative patient cohort, impact of practice variations on the safety and efficacy of the study intervention, likelihood and impact of crossover, and duration of follow-up. Trial interventions and study end points should be predefined, and appropriate strategies must be used to ensure adequate deliverability of the trial interventions. Every effort must be made to ensure a high completeness of follow-up; trial design and analytic techniques must be tailored to the specific research question and trial setting.
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O'Connell NE, Ferraro MC, Gibson W, Rice AS, Vase L, Coyle D, Eccleston C. Implanted spinal neuromodulation interventions for chronic pain in adults. Cochrane Database Syst Rev 2021; 12:CD013756. [PMID: 34854473 PMCID: PMC8638262 DOI: 10.1002/14651858.cd013756.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Implanted spinal neuromodulation (SNMD) techniques are used in the treatment of refractory chronic pain. They involve the implantation of electrodes around the spinal cord (spinal cord stimulation (SCS)) or dorsal root ganglion (dorsal root ganglion stimulation (DRGS)), and a pulse generator unit under the skin. Electrical stimulation is then used with the aim of reducing pain intensity. OBJECTIVES To evaluate the efficacy, effectiveness, adverse events, and cost-effectiveness of implanted spinal neuromodulation interventions for people with chronic pain. SEARCH METHODS We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science (ISI), Health Technology Assessments, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry from inception to September 2021 without language restrictions, searched the reference lists of included studies and contacted experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing SNMD interventions with placebo (sham) stimulation, no treatment or usual care; or comparing SNMD interventions + another treatment versus that treatment alone. We included participants ≥ 18 years old with non-cancer and non-ischaemic pain of longer than three months duration. Primary outcomes were pain intensity and adverse events. Secondary outcomes were disability, analgesic medication use, health-related quality of life (HRQoL) and health economic outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened database searches to determine inclusion, extracted data and evaluated risk of bias for prespecified results using the Risk of Bias 2.0 tool. Outcomes were evaluated at short- (≤ one month), medium- four to eight months) and long-term (≥12 months). Where possible we conducted meta-analyses. We used the GRADE system to assess the certainty of evidence. MAIN RESULTS We included 15 unique published studies that randomised 908 participants, and 20 unique ongoing studies. All studies evaluated SCS. We found no eligible published studies of DRGS and no studies comparing SCS with no treatment or usual care. We rated all results evaluated as being at high risk of bias overall. For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as low or very low, downgraded due to limitations of studies, imprecision and in some cases, inconsistency. Active stimulation versus placebo SCS versus placebo (sham) Results were only available at short-term follow-up for this comparison. Pain intensity Six studies (N = 164) demonstrated a small effect in favour of SCS at short-term follow-up (0 to 100 scale, higher scores = worse pain, mean difference (MD) -8.73, 95% confidence interval (CI) -15.67 to -1.78, very low certainty). The point estimate falls below our predetermined threshold for a clinically important effect (≥10 points). No studies reported the proportion of participants experiencing 30% or 50% pain relief for this comparison. Adverse events (AEs) The quality and inconsistency of adverse event reporting in these studies precluded formal analysis. Active stimulation + other intervention versus other intervention alone SCS + other intervention versus other intervention alone (open-label studies) Pain intensity Mean difference Three studies (N = 303) demonstrated a potentially clinically important mean difference in favour of SCS of -37.41 at short term (95% CI -46.39 to -28.42, very low certainty), and medium-term follow-up (5 studies, 635 participants, MD -31.22 95% CI -47.34 to -15.10 low-certainty), and no clear evidence for an effect of SCS at long-term follow-up (1 study, 44 participants, MD -7 (95% CI -24.76 to 10.76, very low-certainty). Proportion of participants reporting ≥50% pain relief We found an effect in favour of SCS at short-term (2 studies, N = 249, RR 15.90, 95% CI 6.70 to 37.74, I2 0% ; risk difference (RD) 0.65 (95% CI 0.57 to 0.74, very low certainty), medium term (5 studies, N = 597, RR 7.08, 95 %CI 3.40 to 14.71, I2 = 43%; RD 0.43, 95% CI 0.14 to 0.73, low-certainty evidence), and long term (1 study, N = 87, RR 15.15, 95% CI 2.11 to 108.91 ; RD 0.35, 95% CI 0.2 to 0.49, very low certainty) follow-up. Adverse events (AEs) Device related No studies specifically reported device-related adverse events at short-term follow-up. At medium-term follow-up, the incidence of lead failure/displacement (3 studies N = 330) ranged from 0.9 to 14% (RD 0.04, 95% CI -0.04 to 0.11, I2 64%, very low certainty). The incidence of infection (4 studies, N = 548) ranged from 3 to 7% (RD 0.04, 95%CI 0.01, 0.07, I2 0%, very low certainty). The incidence of reoperation/reimplantation (4 studies, N =5 48) ranged from 2% to 31% (RD 0.11, 95% CI 0.02 to 0.21, I2 86%, very low certainty). One study (N = 44) reported a 55% incidence of lead failure/displacement (RD 0.55, 95% CI 0.35, 0 to 75, very low certainty), and a 94% incidence of reoperation/reimplantation (RD 0.94, 95% CI 0.80 to 1.07, very low certainty) at five-year follow-up. No studies provided data on infection rates at long-term follow-up. We found reports of some serious adverse events as a result of the intervention. These included autonomic neuropathy, prolonged hospitalisation, prolonged monoparesis, pulmonary oedema, wound infection, device extrusion and one death resulting from subdural haematoma. Other No studies reported the incidence of other adverse events at short-term follow-up. We found no clear evidence of a difference in otherAEs at medium-term (2 studies, N = 278, RD -0.05, 95% CI -0.16 to 0.06, I2 0%) or long term (1 study, N = 100, RD -0.17, 95% CI -0.37 to 0.02) follow-up. Very limited evidence suggested that SCS increases healthcare costs. It was not clear whether SCS was cost-effective. AUTHORS' CONCLUSIONS We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.
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Affiliation(s)
- Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Andrew Sc Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Doug Coyle
- Epidemiology and Community Medicine, Ottawa Health Research Institute, Ottawa, Canada
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences, Brunel University London, Uxbridge, UK
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Robson S, McParlin C, Mossop H, Lie M, Fernandez-Garcia C, Howel D, Graham R, Ternent L, Steel A, Goudie N, Nadeem A, Phillipson J, Shehmar M, Simpson N, Tuffnell D, Campbell I, Williams R, O'Hara ME, McColl E, Nelson-Piercy C. Ondansetron and metoclopramide as second-line antiemetics in women with nausea and vomiting in pregnancy: the EMPOWER pilot factorial RCT. Health Technol Assess 2021; 25:1-116. [PMID: 34782054 DOI: 10.3310/hta25630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Around one-third of pregnant women suffer from moderate to severe nausea and vomiting, causing physical and emotional distress and reducing their quality of life. There is no cure for nausea and vomiting in pregnancy. Management focuses on relieving symptoms and preventing morbidity, and often requires antiemetic therapy. National guidelines make recommendations about first-, second- and third-line antiemetic therapies, although care varies in different hospitals and women report feeling unsupported, dissatisfied and depressed. OBJECTIVES To determine whether or not, in addition to intravenous rehydration, ondansetron compared with no ondansetron and metoclopramide compared with no metoclopramide reduced the rate of treatment failure up to 10 days after drug initiation; improved symptom severity at 2, 5 and 10 days after drug initiation; improved quality of life at 10 days after drug initiation; and had an acceptable side effect and safety profile. To estimate the incremental cost per treatment failure avoided and the net monetary benefits from the perspectives of the NHS and women. DESIGN This was a multicentre, double-dummy, randomised, double-blinded, dummy-controlled 2 × 2 factorial trial (with an internal pilot phase), with qualitative and health economic evaluations. PARTICIPANTS Thirty-three patients (who were < 17 weeks pregnant and who attended hospital with nausea and vomiting after little or no improvement with first-line antiemetic medication) who attended 12 secondary care NHS trusts in England, 22 health-care professionals and 21 women participated in the qualitative evaluation. INTERVENTIONS Participants were randomly allocated to one of four treatment groups (1 : 1 : 1: 1 ratio): (1) metoclopramide and dummy ondansetron; (2) ondansetron and dummy metoclopramide; (3) metoclopramide and ondansetron; or (4) double dummy. Trial medication was initially given intravenously and then continued orally once women were able to tolerate oral fluids for a maximum of 10 days of treatment. MAIN OUTCOME MEASURES The primary end point was the number of participants who experienced treatment failure, which was defined as the need for further treatment because symptoms had worsened between 12 hours and 10 days post treatment. The main economic outcomes were incremental cost per additional successful treatment and incremental net benefit. RESULTS Of the 592 patients screened, 122 were considered eligible and 33 were recruited into the internal pilot (metoclopramide and dummy ondansetron, n = 8; ondansetron and dummy metoclopramide, n = 8; metoclopramide and ondansetron, n = 8; double dummy, n = 9). Owing to slow recruitment, the trial did not progress beyond the pilot. Fifteen out of 30 evaluable participants experienced treatment failure. No statistical analyses were performed. The main reason for ineligibility was prior treatment with trial drugs, reflecting an unpredicted change in prescribing practice at several points along the care pathway. The qualitative evaluation identified the requirements of the study protocol, in relation to guidelines on anti-sickness drugs, and the diversity of pathways to care as key hurdles to recruitment while the role of research staff was a key enabler. No important adverse events or side effects were reported. LIMITATIONS The pilot trial failed to achieve the recruitment target owing to unforeseen changes in the provision of care. CONCLUSIONS The trial was unable to provide evidence to support clinician decisions about the best choice of second-line antiemetic for nausea and vomiting in pregnancy. TRIAL REGISTRATION Current Controlled Trials ISRCTN16924692 and EudraCT 2017-001651-31. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 63. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stephen Robson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine McParlin
- Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Helen Mossop
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Mabel Lie
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Cristina Fernandez-Garcia
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ruth Graham
- School of Geography, Politics and Sociology, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Alison Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola Goudie
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Afnan Nadeem
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Julia Phillipson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Manjeet Shehmar
- Gynaecology Secretaries Department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nigel Simpson
- Leeds Institute of Medical Research, Department of Women's and Children's Health, School of Medicine, University of Leeds, Leeds, UK
| | - Derek Tuffnell
- Department of Obstetrics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ian Campbell
- Pharmacy Department, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Elaine McColl
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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22
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Peters JPM, van Heteren JAA, Wendrich AW, van Zanten GA, Grolman W, Stokroos RJ, Smit AL. Short-term outcomes of cochlear implantation for single-sided deafness compared to bone conduction devices and contralateral routing of sound hearing aids-Results of a Randomised controlled trial (CINGLE-trial). PLoS One 2021; 16:e0257447. [PMID: 34644322 PMCID: PMC8513831 DOI: 10.1371/journal.pone.0257447] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 08/22/2021] [Indexed: 02/06/2023] Open
Abstract
Single-sided deafness (SSD) leads to difficulties with speech perception in noise, sound localisation, and sometimes tinnitus. Current treatments (Contralateral Routing of Sound hearing aids (CROS) and Bone Conduction Devices (BCD)) do not sufficiently overcome these problems. Cochlear implants (CIs) may help. Our aim was to evaluate these treatments in a Randomised Controlled Trial (RCT). Adult SSD patients were randomised using a web-based randomisation tool into one of three groups: CI; trial period of ‘first BCD, then CROS’; trial period of ‘first CROS, then BCD’. After these trial periods, patients opted for BCD, CROS, or No treatment. The primary outcome was speech perception in noise (directed from the front (S0N0)). Secondary outcomes were speech perception in noise with speech directed to the poor ear and noise to the better ear (SpeNbe) and vice versa (SbeNpe), sound localisation, tinnitus burden, and disease-specific quality of life (QoL). We described results at baseline (unaided situation) and 3 and 6 months after device activation. 120 patients were randomised. Seven patients did not receive the allocated intervention. The number of patients per group after allocation was: CI (n = 28), BCD (n = 25), CROS (n = 34), and No treatment (n = 26). In S0N0, the CI group performed significantly better when compared to baseline, and when compared to the other groups. In SpeNbe, there was an advantage for all treatment groups compared to baseline. However, in SbeNpe, BCD and CROS groups performed worse compared to baseline, whereas the CI group improved. Only in the CI group sound localisation improved and tinnitus burden decreased. In general, all treatment groups improved on disease-specific QoL compared to baseline. This RCT demonstrates that cochlear implantation for SSD leads to improved speech perception in noise, sound localisation, tinnitus burden, and QoL after 3 and 6 months of follow-up. For most outcome measures, CI outperformed BCD and CROS. Trial registration: Netherlands Trial Register (www.trialregister.nl): NTR4580, CINGLE-trial.
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Affiliation(s)
- Jeroen P. M. Peters
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan A. A. van Heteren
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne W. Wendrich
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijsbert A. van Zanten
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Robert J. Stokroos
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Adriana L. Smit
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
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23
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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24
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Placebo Surgery Controlled Trials: Do They Achieve What They Set Out To Do? A Systematic Review. Ann Surg 2021; 273:1102-1107. [PMID: 33351467 DOI: 10.1097/sla.0000000000004719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To explore whether placebo surgery controlled trials achieve what they set out to do by investigating discrepancy between projected and actual design aspects of trials identified through systematic review methods. SUMMARY BACKGROUND Interest in placebo surgery controlled trials is growing in response to concerns regarding unnecessary surgery and the societal cost of low-value healthcare. As questions about the justifiability of using placebo controls in surgery have been addressed, attention is now being paid to more practical concerns. METHODS Six databases were searched from inception - May 2020 (MEDLINE, Embase, Emcare, APA PsycInfo, CINAHL, Cochrane Library). Placebo surgery controlled trials with a published protocol were included. Three authors extracted "projected" design aspects from protocols and "actual" design aspects from main findings papers. Absolute and relative difference between projected and actual design aspects were presented for each trial. Trials were grouped according to whether they met their target sample size ("completed") and were concluded in a timely fashion. Pairs of authors assessed risk of bias. RESULTS Of 24 trials with data available to analyse; 3 were completed and concluded within target timeframe; 10 were completed and concluded outside the target timeline; 4 were completed without clear target timeframes; 2 were incomplete and concluded within the target framework; 5 were incomplete and concluded outside the target timeline. Trials which reached the recruitment target underestimated trial duration by 88% and number of recruitment sites by 87%. CONCLUSIONS Trialists need to factor additional time and sites into future placebo surgery controlled trials. A robust reporting framework of projected and actual trial design is imperative for trialists to learn from their predecessors. REVIEW REGISTRATION PROSPERO (CRD42019133296).
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25
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Mulcahy MJ, Elalingam T, Jang K, D'Souza M, Tait M. Bilateral cervical plexus block for anterior cervical spine surgery: study protocol for a randomised placebo-controlled trial. Trials 2021; 22:424. [PMID: 34187541 PMCID: PMC8244165 DOI: 10.1186/s13063-021-05377-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 06/15/2021] [Indexed: 11/28/2022] Open
Abstract
Background There has been increasing focus to improve the quality of recovery following anterior cervical spine surgery (ACSS). Postoperative pain and nausea are the most common reasons for prolonged hospital stay and readmission after ACSS. Superficial cervical plexus block (SCPB) provides site-specific analgesia with minimal side effects, thereby improving the quality of recovery. The aim of our study was to investigate the effect bilateral cervical plexus block has on postoperative recovery in patients undergoing ACSS. Methods The study is a pragmatic, multi-centre, blinded, parallel-group, randomised placebo-controlled trial. 136 eligible patients (68 in each group) undergoing ACSS will be included. Patients randomised to the intervention group will have a SCPB administered under ultrasound guidance with a local anaesthetic solution (0.2% ropivacaine, 15mL); patients randomised to the placebo group will be injected in an identical manner with a saline solution. The primary outcome is the 40-item quality of recovery questionnaire score at 24 h after surgery. In addition, comparisons between groups will be made for a 24-h opioid usage and length of hospital stay. Neck pain intensity will be quantified using the numeric rating scale at 1, 3, 6 and at 24 h postoperatively. Incidence of nausea, vomiting, dysphagia or hoarseness in the first 24 h after surgery will also be measured. Discussion By conducting a blinded placebo trial, we aim to control for the bias inherently associated with a tangible medical intervention and show the true treatment effect of SCPB in ACSS. A statistically significant result will indicate an overall improved quality of recovery for patients; alternatively, if no benefit is shown, this trial will provide evidence that this intervention is unnecessary. Trial registration ClinicalTrials.gov ACTRN12619000028101. Prospectively registered on 11 January 2019 with Australia New Zealand Clinical Trials Registry
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Affiliation(s)
- Michael J Mulcahy
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia. .,Macquarie Neurosurgery, Suite 201, 2 Technology Place, Sydney, Australia.
| | - Thananchayan Elalingam
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Kevin Jang
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia
| | - Mario D'Souza
- Central Clinical School, University of Sydney, Sydney, Australia
| | - Matthew Tait
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia.,Macquarie Neurosurgery, Suite 201, 2 Technology Place, Sydney, Australia
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26
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Whitaker LHR, Doust A, Stephen J, Norrie J, Cooper K, Daniels J, Hummelshoj L, Cox E, Beatty L, Chien P, Madhra M, Vincent K, Horne AW. Laparoscopic treatment of isolated superficial peritoneal endometriosis for managing chronic pelvic pain in women: study protocol for a randomised controlled feasibility trial (ESPriT1). Pilot Feasibility Stud 2021; 7:19. [PMID: 33413677 PMCID: PMC7788382 DOI: 10.1186/s40814-020-00740-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/30/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Endometriosis (where endometrial-like tissue is found outside the uterus) affects ~ 176 million women worldwide and can lead to debilitating pelvic pain. Three subtypes of endometriosis exist, with ~ 80% of women having superficial peritoneal endometriosis (SPE). Endometriosis is diagnosed by laparoscopy and, if SPE is found, gynaecologists usually remove it surgically. However, many women get limited pain relief from surgical removal of SPE. We plan to undertake a future large trial where women who have only SPE found at initial laparoscopy are randomly allocated to have surgical removal (excision or ablation) of SPE, or not. Ultimately, we want to determine whether surgical removal improves overall symptoms and quality of life, or whether surgery is of no benefit, exacerbates symptoms, or even causes harm. The primary objective of this feasibility study is to determine what proportion of women with suspected SPE undergoing diagnostic laparoscopy will agree to randomisation. The secondary objectives are to determine if there are differences in key prognostic parameters between eligible women that agree to be randomised and those that decline; how many women having laparoscopy for investigation of chronic pelvic pain are eligible for the trial; the range of treatment effects and variability in outcomes and the most acceptable methods of recruitment, randomisation and assessment tools. METHODS We will recruit up to 90 women with suspected SPE undergoing diagnostic laparoscopy over a 9-month recruitment period in four Scottish hospitals and randomise them 1:1 to either diagnostic laparoscopy alone (with a sham port to achieve blinding of the allocation) or surgical removal of endometriosis. Baseline characteristics, e.g. age, index of social deprivation, ethnicity, and intensity/duration of pain will be collected. Participants will be followed up by online questionnaires assessing pain, physical and emotional function at baseline, 3 months, 6 months and 12 months. DISCUSSION Recruitment to a randomised controlled trial to assess the effectiveness of surgery for endometriosis may be challenging because of preconceived ideas about treatment success amongst patients and clinicians. We have designed this study to assess feasibility of recruitment and to inform the design of our future definitive trial. TRIAL REGISTRATION ClincicalTrials.gov, NCT04081532 STATUS: Recruiting.
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Affiliation(s)
- Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Ann Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jacqueline Stephen
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh NINE Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh NINE Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Kevin Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, School of Medicine, Nottingham Health Sciences Partners, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | | | | | - Laura Beatty
- NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | | | - Mayank Madhra
- NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX3 9DU, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK.
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27
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Crocker JC, Farrar N, Cook JA, Treweek S, Woolfall K, Chant A, Bostock J, Locock L, Rees S, Olszowski S, Bulbulia R. Recruitment and retention of participants in UK surgical trials: survey of key issues reported by trial staff. BJS Open 2020; 4:1238-1245. [PMID: 33016008 PMCID: PMC7709375 DOI: 10.1002/bjs5.50345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 07/21/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recruitment and retention of participants in surgical trials is challenging. Knowledge of the most common and problematic issues will aid future trial design. This study aimed to identify trial staff perspectives on the main issues affecting participant recruitment and retention in UK surgical trials. METHODS An online survey of UK surgical trial staff was performed. Respondents were asked whether or not they had experienced a range of recruitment and retention issues, and, if yes, how relatively problematic these were (no, mild, moderate or serious problem). RESULTS The survey was completed by 155 respondents including 60 trial managers, 53 research nurses, 20 trial methodologists and 19 chief investigators. The three most common recruitment issues were: patients preferring one treatment over another (81·5 per cent of respondents); clinicians' time constraints (78·1 per cent); and clinicians preferring one treatment over another (76·8 per cent). Seven recruitment issues were rated moderate or serious problems by a majority of respondents, the most problematic being a lack of eligible patients (60·3 per cent). The three most common retention issues were: participants forgetting to return questionnaires (81·4 per cent); participants found to be ineligible for the trial (74·3 per cent); and long follow-up period (70·7 per cent). The most problematic retention issues, rated moderate or serious by the majority of respondents, were participants forgetting to return questionnaires (56·4 per cent) and insufficient research nurse time/funding (53·6 per cent). CONCLUSION The survey identified a variety of common recruitment and retention issues, several of which were rated moderate or serious problems by the majority of participating UK surgical trial staff. Mitigation of these problems may help boost recruitment and retention in surgical trials.
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Affiliation(s)
- J. C. Crocker
- Nuffield Department of Primary Care Health SciencesOxfordUK
- National Institute for Health Research Oxford Biomedical Research CentreOxfordUK
- MRC ConDuCT‐II Hub for Trials Methodology Research, Bristol Medical SchoolBristolUK
| | - N. Farrar
- MRC ConDuCT‐II Hub for Trials Methodology Research, Bristol Medical SchoolBristolUK
- Population Health Sciences, Bristol Medical School, University of BristolBristolUK
| | - J. A. Cook
- Surgical Intervention Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesOxfordUK
- MRC ConDuCT‐II Hub for Trials Methodology Research, Bristol Medical SchoolBristolUK
| | - S. Treweek
- Health Services Research Unit, University of AberdeenAberdeenUK
| | - K. Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health and Society, University of LiverpoolLiverpoolUK
- MRC North West Hub for Trials Methodology ResearchLiverpoolUK
| | - A. Chant
- Patient partnerCookham, BerkshireUK
| | - J. Bostock
- Quality Safety and Outcomes Policy Research Unit, University of KentCanterburyUK
- Policy Innovation and Evaluation Research Unit, London School of Hygiene and Tropical MedicineLondonUK
| | - L. Locock
- Health Services Research Unit, University of AberdeenAberdeenUK
| | - S. Rees
- Oxford Academic Health Science NetworkOxfordUK
| | - S. Olszowski
- National Institute for Health Research Oxford Biomedical Research CentreOxfordUK
- SPZ AssociatesLyme RegisUK
| | - R. Bulbulia
- Clinical Trial Service Unit Hub for Trials Methodology ResearchOxfordUK
- Medical Research Council (MRC) Population Health Unit, Nuffield Department of Population Health, University of OxfordOxfordUK
- Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation TrustCheltenhamUK
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Reply to Banik. Pain 2020; 161:1939-1940. [PMID: 32701853 DOI: 10.1097/j.pain.0000000000001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gorayeb RP, Forjaz MJ, Ferreira AG, Ferreira JJ. Use of Sham Interventions in Randomized Controlled Trials in Neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2020; 81:456-462. [PMID: 32438420 DOI: 10.1055/s-0040-1709161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of sham interventions in randomized controlled trials (RCTs) is essential to minimize bias. However, their use in surgical RCTs is rare and subject to ethical concerns. To date, no studies have looked at the use of sham interventions in RCTs in neurosurgery. METHODS This study evaluated the frequency, type, and indication of sham interventions in RCTs in neurosurgery. RCTs using sham interventions were also characterized in terms of design and risk of bias. RESULTS From a total of 1,102 identified RCTs in neurosurgery, 82 (7.4%) used sham interventions. The most common indication for the RCT was the treatment of pain (67.1%), followed by the treatment of movement disorders and other clinical problems (18.3%) and brain injuries (12.2%). The most used sham interventions were saline injections into spinal structures (31.7%) and peripheral nerves (10.9%), followed by sham interventions in cranial surgery (26.8%), and spine surgery (15.8%). Insertion of probes or catheters for a sham lesions was performed in 14.6%.In terms of methodology, most RCTs using sham interventions were double blinded (76.5%), 9.9% were single blinded, and 13.6% did not report the type of blinding. CONCLUSION Sham-controlled RCTs in neurosurgery are feasible. Most aim to minimize bias and to evaluate the efficacy of pain management methods, especially in spinal disorders. The greatest proportion of sham-controlled RCTs involves different types of substance administration routes, with sham surgery the less commonly performed.
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Affiliation(s)
- Rodrigo Panico Gorayeb
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Maria João Forjaz
- National School of Public Health, Institute of Health Carlos III and REDISSEC, Madrid, Spain
| | | | - Joaquim José Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal.,Instituto de Medicina Molecular, Lisbon, Portugal
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Cousins S, Blencowe NS, Tsang C, Chalmers K, Mardanpour A, Carr AJ, Campbell MK, Cook JA, Beard DJ, Blazeby JM. Optimizing the design of invasive placebo interventions in randomized controlled trials. Br J Surg 2020; 107:1114-1122. [PMID: 32187680 PMCID: PMC7496319 DOI: 10.1002/bjs.11509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/11/2019] [Accepted: 12/13/2019] [Indexed: 01/09/2023]
Abstract
Background Placebo‐controlled trials play an important role in the evaluation of healthcare interventions. However, they can be challenging to design and deliver for invasive interventions, including surgery. In‐depth understanding of the component parts of the treatment intervention is needed to ascertain what should, and should not, be delivered as part of the placebo. Assessment of risk to patients and strategies to ensure that the placebo effectively mimics the treatment are also required. To date, no guidance exists for the design of invasive placebo interventions. This study aimed to develop a framework to optimize the design and delivery of invasive placebo interventions in
RCTs. Methods A preliminary framework was developed using published literature to: expand the scope of an existing typology, which facilitates the deconstruction of invasive interventions; and identify placebo optimization strategies. The framework was refined after consultation with key stakeholders in surgical trials, consensus methodology and medical ethics. Results The resulting DITTO framework consists of five stages: deconstruct treatment intervention into constituent components and co‐interventions; identify critical surgical element(s); take out the critical element(s); think risk, feasibility and role of placebo in the trial when considering remaining components; and optimize placebo to ensure effective blinding of patients and trial personnel. Conclusion DITTO considers invasive placebo composition systematically, accounting for risk, feasibility and placebo optimization. Use of the framework can support the design of high‐quality RCTs, which are needed to underpin delivery of healthcare interventions.
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Affiliation(s)
- S Cousins
- National Institute for Health Research (NIHR) Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Surgical Innovation Theme.,Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School
| | - N S Blencowe
- National Institute for Health Research (NIHR) Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Surgical Innovation Theme.,Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School.,Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol
| | - C Tsang
- National Institute for Health Research (NIHR) Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Surgical Innovation Theme.,Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School
| | - K Chalmers
- National Institute for Health Research (NIHR) Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Surgical Innovation Theme.,Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School
| | - A Mardanpour
- National Institute for Health Research (NIHR) Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Surgical Innovation Theme.,Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School
| | - A J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Centre, University of Oxford
| | - M K Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - J A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Centre, University of Oxford.,Royal College of Surgeons (England) Surgical Interventional Trials Unit, University of Oxford, Headington, Oxford
| | - D J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Centre, University of Oxford.,Royal College of Surgeons (England) Surgical Interventional Trials Unit, University of Oxford, Headington, Oxford
| | - J M Blazeby
- National Institute for Health Research (NIHR) Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Surgical Innovation Theme.,Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School.,Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris IA, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Cook JA. Considerations and methods for placebo controls in surgical trials (ASPIRE guidelines). Lancet 2020; 395:828-838. [PMID: 32145797 DOI: 10.1016/s0140-6736(19)33137-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/13/2019] [Accepted: 12/06/2019] [Indexed: 01/09/2023]
Abstract
Placebo comparisons are increasingly being considered for randomised trials assessing the efficacy of surgical interventions. The aim of this Review is to provide a summary of knowledge on placebo controls in surgical trials. A placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. This Review outlines what a placebo control entails and present understanding of this tool in the context of surgery. We consider when placebo controls in surgery are acceptable (and when they are desirable) in terms of ethical arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be done and interpreted. Use of placebo controls is justified in randomised controlled trials of surgical interventions provided there is a strong scientific and ethical rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with high risk of bias, particularly because of the placebo effect. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. This Review forms an outline for best practice and provides guidance, in the form of the Applying Surgical Placebo in Randomised Evaluations (known as ASPIRE) checklist, for those considering the use of a placebo control in a surgical randomised controlled trial.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK.
| | - Marion K Campbell
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, UK
| | - Jane M Blazeby
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Charles Weijer
- Rotman Institute of Philosophy, Western Interdisciplinary Research Building, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Cabrini-Monash Department of Clinical Epidemiology, Cabrini Institute and Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, Heritage Building, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Department of Orthopaedics Lund, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK; University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Amar Rangan
- Department of Health Sciences, Seebohm Rowntree Building, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; Old Road Campus Research Building, University of Oxford, Oxford, UK
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Cousins S, Blencowe NS, Tsang C, Lorenc A, Chalmers K, Carr AJ, Campbell MK, Cook JA, Beard DJ, Blazeby JM. Reporting of key methodological issues in placebo-controlled trials of surgery needs improvement: a systematic review. J Clin Epidemiol 2020; 119:109-116. [PMID: 31786153 PMCID: PMC7066579 DOI: 10.1016/j.jclinepi.2019.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/12/2019] [Accepted: 11/24/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To examine key methodological considerations for using a placebo intervention in randomized controlled trials (RCTs) evaluating invasive procedures, including surgery. STUDY DESIGN AND SETTING RCTs comparing an invasive procedure with a placebo were included in this systematic review. Articles published from database inception to December 31, 2017, were retrieved from Ovid MEDLINE, Ovid EMBASE and CENTRAL electronic databases, by handsearching references and expert knowledge. Data on trial characteristics (clinical area, nature of invasive procedure, number of patients and centers) and key methodological (rationale for using placebos, minimization of risk, information provision, offering the treatment intervention to patients randomized to placebo, delivery of cointerventions, and intervention standardization and fidelity) were extracted and summarized descriptively. RESULTS One hundred thirteen articles reporting 96 RCTs were identified. Most were conducted in gastrointestinal surgery (n = 40, 42%) and evaluated minimally invasive procedures (n = 44, 46%). Over two-thirds randomized fewer than 100 patients (n = 65, 68%) and a third were single center (n = 31, 32%). A third (n = 33, 34%) did not report a rationale for using a placebo. Most common strategies to minimize patient risk were operator skill (n = 22, 23%) and independent data monitoring (n = 28, 29%). Provision of patient information regarding placebo use was infrequently reported (n = 11, 11%). Treatment interventions were offered to patients randomized to placebo in 43 trials (45%). Cointerventions were inconsistently reported, but 64 trials (67%) stated that anesthesia was matched between groups. Attempts to standardize interventions and monitor their delivery were reported in n = 7, (7%) and n = 4, (4%) trials, respectively. CONCLUSION Most placebo-controlled trials in surgery evaluate minor surgical procedures and currently there is inconsistent reporting of key trial methods. There is a need for guidance to optimize the transparency of trial reporting in this area.
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Affiliation(s)
- Sian Cousins
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.
| | - Natalie S Blencowe
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Carmen Tsang
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Ava Lorenc
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Katy Chalmers
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jane M Blazeby
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Sum SK, Peng YC, Yin SY, Huang PF, Wang YC, Chen TP, Tung HH, Yeh CH. Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial. Trials 2019; 20:797. [PMID: 31888765 PMCID: PMC6937666 DOI: 10.1186/s13063-019-3943-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/28/2019] [Indexed: 11/13/2022] Open
Abstract
Background An incentive spirometer (IS) is a mechanical device that promotes lung expansion. It is commonly used to prevent postoperative lung atelectasis and decrease pulmonary complications after cardiac, lung, or abdominal surgery. This study explored its effect on lung function and pulmonary complication rates in patients with rib fractures. Methods Between June 2014 and May 2017, 50 adult patients with traumatic rib fractures were prospectively investigated. Patients who were unconscious, had a history of chronic obstructive pulmonary disease or asthma, or an Injury Severity Score (ISS) ≥ 16 were excluded. Patients were randomly divided into a study group (n = 24), who underwent IS therapy, and a control group (n = 26). All patients received the same analgesic protocol. Chest X-rays and pulmonary function tests (PFTs) were performed on the 5th and 7th days after trauma. Results The groups were considered demographically homogeneous. The mean age was 55.2 years and 68% were male. Mean pretreatment ISSs and mean number of ribs fractured were not significantly different (8.23 vs. 8.08 and 4 vs. 4, respectively). Of 50 patients, 28 (56%) developed pulmonary complications, which were more prevalent in the control group (80.7% vs. 29.2%; p = 0.001). Altogether, 25 patients had delayed hemothorax, which was more prevalent in the control group (69.2% vs. 29.2%; p = 0.005). Two patients in the control group developed atelectasis, one patient developed pneumothorax, and five patients required thoracostomy. PFT results showed decreased forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) in the control group. Comparing pre- and posttreatment FVC and FEV1, the study group had significantly greater improvements (p < 0.001). Conclusions In conclusion, the use of an IS reduced pulmonary complications and improved PFT results in patients with rib fractures. The IS is a cost-effective device for patients with rib fractures and its use has clinical benefits without harmful effects. Trial registration ClinicalTrials.gov, NCT04006587. Registered on 3 July 2019.
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Affiliation(s)
- Shao-Kai Sum
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung, 204, Taiwan, Republic of China
| | - Ya-Chuan Peng
- Department of Nursing, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shun-Ying Yin
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung, 204, Taiwan, Republic of China
| | - Pin-Fu Huang
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung, 204, Taiwan, Republic of China
| | - Yao-Chang Wang
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung, 204, Taiwan, Republic of China
| | - Tzu-Ping Chen
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung, 204, Taiwan, Republic of China
| | - Heng-Hsin Tung
- School of Nursing, National Taipei University of Nursing and Health Science, Taipei, Taiwan
| | - Chi-Hsiao Yeh
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung, 204, Taiwan, Republic of China. .,School of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
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Slynarski K, Walawski J, Smigielski R, van der Merwe W. Two-Year Results of the PHANTOM High Flex Trial: A Single-Arm Study on the Atlas Unicompartmental Knee System Load Absorber in Patients With Medial Compartment Osteoarthritis of the Knee. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2019; 12:1179544119877170. [PMID: 31579106 PMCID: PMC6757501 DOI: 10.1177/1179544119877170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 11/16/2022]
Abstract
The Atlas Knee System was designed to fill the gap between no longer effective conservative treatments and more invasive surgery for young patients with medial knee osteoarthritis (OA). This article reports on the 2-year results of a single-arm study of 26 subjects who previously reported favorable clinical outcomes 1 year post implantation. Western Ontario and McMaster Universities Osteoarthritis Index pain and function scores improved by a clinically meaningful amount relative to baseline, and subjects had a return to normal range of motion. This study confirmed that the benefit of a joint unloading device in the management of young patients with medial knee OA is maintained over 2 years. This trial was registered with ClinicalTrials.gov (NCT02711254).
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Affiliation(s)
- Konrad Slynarski
- Lekmed Medical Center, Warsaw, Poland.,CM Gamma Hospital, Warsaw, Poland
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Teira D. Placebo trials without mechanisms: How far can they go? STUDIES IN HISTORY AND PHILOSOPHY OF BIOLOGICAL AND BIOMEDICAL SCIENCES 2019; 77:101177. [PMID: 31221503 DOI: 10.1016/j.shpsc.2019.101177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/17/2019] [Accepted: 06/10/2019] [Indexed: 06/09/2023]
Abstract
In this paper, I suggest that placebo effects, as we know them today, should be understood as experimental phenomena, low-level regularities whose causal structure is grasped through particular experimental designs with little theoretical guidance. Focusing on placebo interventions with needles for pain reduction -one of the few placebo regularities that seems to arise in meta-analytical studies- I discuss the extent to which it is possible to decompose the different factors at play through more fine-grained randomized clinical trials. My sceptical argument is twofold. On the one hand, I argue that experiments alone are not enough to standardize interventions, and that it is necessary to include theories. On the other hand, I argue that the social interactions that seem to be part of placebo effects are difficult, if not impossible, to blind. Therefore, the measurement biases arising from the participants' reactivity to the experimental setup cannot be controlled for. Further decomposition of placebo effects requires a theoretical account of the existing experimental regularities that may guide further tests.
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Affiliation(s)
- David Teira
- Dpto. de Lógica, Historia y Filosofía de la ciencia, UNED, Senda del rey 7 | 28040, Madrid, Spain.
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Vase L, Wartolowska K. Pain, placebo, and test of treatment efficacy: a narrative review. Br J Anaesth 2019; 123:e254-e262. [PMID: 30915982 PMCID: PMC6676016 DOI: 10.1016/j.bja.2019.01.040] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 01/09/2023] Open
Abstract
Over the past decade, the mechanisms underlying placebo effects have begun to be identified. At the same time, the placebo response appears to have increased in pharmacological trials and marked placebo effects are found in neurostimulation and surgical trials, thereby posing the question whether non-pharmacological interventions should be placebo-controlled to a greater extent. In this narrative review we discuss how the knowledge of placebo mechanisms may help to improve placebo control in pharmacological and non-pharmacological trials. We review the psychological, neurobiological, and genetic mechanisms underlying placebo analgesia and outline the current problems and potential solutions to the challenges with placebo control in trials on pharmacological, neurostimulation, and surgical interventions. We particularly focus on how patients' perception of the therapeutic intervention, and their expectations towards treatment efficacy may help develop more precise placebo controls and blinding procedures and account for the contribution of placebo factors to the efficacy of active treatments. Finally, we discuss how systematic investigations into placebo mechanisms across various pain conditions and types of treatment are needed in order to 'personalise' the placebo control to the specific pathophysiology and interventions, which may ultimately lead to identification of more effective treatment for pain patients. In conclusion this review shows that it is important to understand how patients' perception and expectations influence the efficacy of active and placebo treatments in order to improve the test of new treatments. Importantly, this applies not only to assessment of drug efficacy but also to non-pharmacological trials on surgeries and stimulation procedures.
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Affiliation(s)
- Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark.
| | - Karolina Wartolowska
- Nuffield Department of Primary Care Health Services, University of Oxford, Oxford, UK.
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Cousins S, Blencowe NS, Blazeby JM. What is an invasive procedure? A definition to inform study design, evidence synthesis and research tracking. BMJ Open 2019; 9:e028576. [PMID: 31366651 PMCID: PMC6678000 DOI: 10.1136/bmjopen-2018-028576] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Worldwide, there are at least 230 million invasive procedures performed annually and most of us will undergo several in our lifetime. There is therefore a need for high-quality evidence to underpin this clinical area. Currently, however, there is no widely accepted definition of an invasive procedure and the terms 'surgery' and 'interventional procedure' are characterised inconsistently. We propose a definition for invasive procedures which addresses the limitations of those currently available. Our definition was developed from an analysis of the 3946 papers from the last decade. A preliminary definition was created based on existing definitions and applied to a variety of papers reporting all types of procedures. This definition was continuously updated and applied iteratively to all articles. The definition has three key components: (1) method of access to the body, (2) instrumentation and (3) requirement for operator skill. It therefore encapsulates all types of invasive procedure regardless of the method of access to the body (incision, natural orifice or percutaneous access), and is relevant whatever the clinical discipline (eg, obstetric, cardiac, dental, interventional cardiology or radiology). Crucially, the definition excludes medicinal products, except where their administration occurs within an invasive procedure (and thereby involves operator skill). The application of a universal definition of an invasive procedure will (1) inform the selection of relevant methods for study design, (2) streamline evidence synthesis and (3) improve research tracking, helping to identify evidence gaps and direct research funds.
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Affiliation(s)
- Sian Cousins
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
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Khatri C, Ahmed I, Parsons H, Smith NA, Lawrence TM, Modi CS, Drew SJ, Bhabra G, Parsons NR, Underwood M, Metcalfe AJ. The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis. Am J Sports Med 2019; 47:1734-1743. [PMID: 29963905 DOI: 10.1177/0363546518780694] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known. PURPOSE To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials. STUDY DESIGN Systematic review and meta-analysis. METHODS Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores. RESULTS A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms. CONCLUSION Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.
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Affiliation(s)
- Chetan Khatri
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Imran Ahmed
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Helen Parsons
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Nicholas A Smith
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Thomas M Lawrence
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Chetan S Modi
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Stephen J Drew
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Gev Bhabra
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Nicholas R Parsons
- Statistics & Epidemiology Unit, University of Warwick Medical School, Coventry, UK
| | - Martin Underwood
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
| | - Andrew J Metcalfe
- Clinical Trials Unit, University of Warwick Medical School, Coventry, UK
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Bateman M, Littlewood C, Rawson B, Tambe AA. Surgery for tennis elbow: a systematic review. Shoulder Elbow 2019; 11:35-44. [PMID: 30719096 PMCID: PMC6348580 DOI: 10.1177/1758573217745041] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 10/25/2017] [Accepted: 10/31/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is no consensus on the most suitable treatment for tennis elbow but, in the USA, surgical intervention is increasing despite a lack of supportive research evidence. The aim of this systematic review was to provide a balanced update based on all relevant published randomized controlled trials conducted to date. METHODS An electronic search of MEDLINE, EMBASE, CINAHL, BNI, AMED, PsycINFO, HBE, HMIC, PubMed, TRIP, Dynamed Plus and The Cochrane Library was complemented by hand searching. Risk of bias was assessed using the Cochrane Risk of Bias Tool and data were synthesized narratively, based on levels of evidence, as a result of heterogeneity. RESULTS Twelve studies of poor methodological quality were included. The available data suggest that surgical interventions for tennis elbow are no more effective than nonsurgical and sham interventions. Surgical technique modifications may enhance effectiveness compared to traditional methods but have not been tested against a placebo. CONCLUSIONS Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment based on evidence with significant methodological limitations. Given the recalcitrant nature of tennis elbow for some patients, further research in the form of a high-quality placebo-controlled surgical trial with an additional conservative arm is required to usefully inform clinical practice.
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Affiliation(s)
- Marcus Bateman
- Orthopaedic Department, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Chris Littlewood
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences and Keele Clinical Trials Unit, David Weatherall Building, Keele University, Staffordshire, UK
| | - Beth Rawson
- Library Services, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Amol A. Tambe
- Orthopaedic Department, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
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Wartolowska KA, Beard DJ, Carr AJ. The use of placebos in controlled trials of surgical interventions: a brief history. J R Soc Med 2018; 111:177-182. [PMID: 29746198 PMCID: PMC5958363 DOI: 10.1177/0141076818769833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- KA Wartolowska
- NIHR Musculoskeletal Biomedical Research Unit, Botnar Research Centre, Headington, Oxford OX3 7LD, UK
| | - DJ Beard
- NIHR Musculoskeletal Biomedical Research Unit, Botnar Research Centre, Headington, Oxford OX3 7LD, UK
| | - AJ Carr
- NIHR Musculoskeletal Biomedical Research Unit, Botnar Research Centre, Headington, Oxford OX3 7LD, UK
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Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study. Plast Reconstr Surg 2018; 141:455e-456e. [PMID: 29485594 DOI: 10.1097/prs.0000000000004149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wartolowska K, Beard D, Carr A. Blinding in trials of interventional procedures is possible and worthwhile. F1000Res 2018; 6:1663. [PMID: 29259763 DOI: 10.12688/f1000research.12528.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/31/2022] Open
Abstract
In this paper, we use evidence from our earlier review of surgical randomised controlled trials with a placebo arm to show that blinding in trials of interventional procedures is feasible. We give examples of ingenious strategies that have been used to simulate the active procedure and to make the placebo control indistinguishable from the active treatment. We discuss why it is important to blind of patients, assessors, and caregivers and what types of bias that may occur in interventional trials. Finally, we describe the benefits of blinding, from the obvious ones such as avoiding bias, as well as less evident benefits such as avoiding patient drop out in the control arm.
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Affiliation(s)
- Karolina Wartolowska
- Nuffield Department of Primary Care Health Sciences (NDPCHS), Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - David Beard
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - Andrew Carr
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
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45
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Glasbey JC, Magill EL, Brock K, Bach SP. Recommendations for Randomised Trials in Surgical Oncology. Clin Oncol (R Coll Radiol) 2017; 29:799-810. [PMID: 29097072 DOI: 10.1016/j.clon.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 09/20/2017] [Indexed: 01/06/2023]
Abstract
Trials of surgical procedures in the treatment of malignant disease face a unique set of challenges. This review aimed to describe recommendations for the design, delivery and reporting of randomised trials in surgical oncology. A literature search was carried out without date limits to identify articles related to trial methodology research in surgery and surgical oncology. A narrative review was framed around two open National Institute of Health Research portfolio trials in colon and rectal cancer: the STAR-TREC trial (ISRCTN14240288) and the ROCCS trial (ISRCTN46330337). Twelve specific challenges were highlighted: standardisation of technique; pilot and feasibility studies; balancing treatments; the recruitment pathway; outcome measures; patient and public representation; trainee-led networks; randomisation; novel techniques and training; learning curves; blinding; follow-up. Evidence-based recommendations were made for the future design and conduct of surgical oncology trials. Better understanding of the challenges facing trials in the surgical treatment of cancer will accelerate high-quality evaluation and rapid adoption of innovation for the benefit of patient care.
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Affiliation(s)
- J C Glasbey
- Academic Department of Surgery, University of Birmingham, Birmingham, UK; Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - E L Magill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - K Brock
- Devices, Drugs, Diagnostics and Biomarkers (D3B), Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - S P Bach
- Academic Department of Surgery, University of Birmingham, Birmingham, UK; Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK; Devices, Drugs, Diagnostics and Biomarkers (D3B), Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK.
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Slynarski K, Walawski J, Smigielski R, van der Merwe W. Feasibility of the Atlas Unicompartmental Knee System Load Absorber in Improving Pain Relief and Function in Patients Needing Unloading of the Medial Compartment of the Knee: 1-Year Follow-Up of a Prospective, Multicenter, Single-Arm Pilot Study (PHANTOM High Flex Trial). CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2017; 10:1179544117733446. [PMID: 28989290 PMCID: PMC5624346 DOI: 10.1177/1179544117733446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/16/2017] [Indexed: 12/27/2022]
Abstract
In young patients with medial knee osteoarthritis (OA), surgical intervention may not be desirable due to preferences to avoid bone cutting procedures, return to high activity levels, and prolong implant survival. The Atlas Knee System was designed to fill the gap between ineffective conservative treatments and invasive surgery. This single-arm study included 26 patients, aged 25 to 65 years, who completed 12 months of follow-up. All dimensions of the Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee Society Score significantly improved from baseline to 12 months. About 96.2% and 92.3% of patients experienced a ⩾20% improvement in their KOOS pain and WOMAC pain scores, respectively, at 12 months. This study highlights the potential benefit of a joint unloading device in the management of young patients with medial knee OA. The trial is still ongoing and another analysis is planned at 24 months.
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Affiliation(s)
- Konrad Slynarski
- Lekmed Medical Center, Warsaw, Poland.,Centrum Medyczne Gamma Hospital, Warsaw, Poland
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Wartolowska K, Beard D, Carr A. Blinding in trials of interventional procedures is possible and worthwhile. F1000Res 2017; 6:1663. [PMID: 29259763 PMCID: PMC5717470 DOI: 10.12688/f1000research.12528.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2018] [Indexed: 12/27/2022] Open
Abstract
In this paper, we use evidence from our earlier review of surgical randomised controlled trials with a placebo arm to show that blinding in trials of interventional procedures is feasible. We give examples of ingenious strategies that have been used to simulate the active procedure and to make the placebo control indistinguishable from the active treatment. We discuss why it is important to blind of patients, assessors, and caregivers and what types of bias that may occur in interventional trials. Finally, we describe the benefits of blinding, from the obvious ones such as avoiding bias, as well as less evident benefits such as avoiding patient drop out in the control arm.
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Affiliation(s)
- Karolina Wartolowska
- Nuffield Department of Primary Care Health Sciences (NDPCHS), Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - David Beard
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - Andrew Carr
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
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Moosmayer S, Ekeberg OM, Hallgren HB, Heier I, Kvalheim S, Blomquist J, Pripp AH, Juel NG, Kjellevold SH, Brox JI. KALK study: ultrasound guided needling and lavage (barbotage) with steroid injection versus sham barbotage with and without steroid injection - protocol for a randomized, double-blinded, controlled, multicenter study. BMC Musculoskelet Disord 2017; 18:138. [PMID: 28376756 PMCID: PMC5379547 DOI: 10.1186/s12891-017-1501-9] [Citation(s) in RCA: 7] [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] [Received: 11/23/2016] [Accepted: 03/24/2017] [Indexed: 11/29/2022] Open
Abstract
Background For the treatment of calcific tendinitis of the shoulder a variety of treatment regimes exist. Commonly used treatment measures include medication with oral analgesics, corticosteroid injections, extracorporeal shockwave therapy, ultrasound guided needling and lavage, and surgical treatment. Earlier cohort studies suggest that patients may benefit from these treatments, but there are few randomized studies and conflicting evidence about the effectiveness of the various treatments. In the present study we aim to compare the effectiveness of ultrasound guided needling and lavage (barbotage) together with a steroid injection to sham barbotage with and without an additional steroid injection. Methods The study will be performed in six secondary-care institutions in Norway and Sweden. It is designed as a pragmatic, randomized, three-arm, parallel group, double-blinded, sham-controlled clinical trial with a 2-year follow-up. It will be performed on 210 patients, aged 30 years or older, presenting with painful arc, positive impingement sign and a calcium deposit > 5 mm. Randomization to one of the three treatment options will be performed by using an online central randomization system. The three treatment groups are barbotage together with a subacromial steroid injection (the barbotage group), sham barbotage together with a subacromial steroid injection (the steroid group) or sham barbotage without a subacromial steroid injection (the placebo group). In the placebo group the steroid injection will be replaced by a short-acting local anaesthetic. Standardized home-based post-treatment physiotherapy will be performed by all patients for 8 weeks. Follow-ups are at 2 and 6 weeks, 4, 8, 12 and 24 months after treatment was given and will be performed with the patients and the outcome assessors blinded for group assignment. Primary outcome will be the Oxford shoulder score at 4 month follow-up. Secondary outcome measures are the QuickDASH upper extremity score, the EQ-5D-5L general health score and visual analogue scales for pain at rest, during activity, and at night. Discussion The scientific evidence from this placebo-controlled trial will be of importance for future treatment recommendations in patients with calcific tendinitis. Trial registration ClinicalTrials.gov: NCT02419040, registered 10 April 2015 EudraCT: 2015-002343-34, registered 23 September 2015 (retrospectively registered) Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1501-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Moosmayer
- Orthopedic Department, Martina Hansens Hospital, Dønskiveien 8, 1346, Gjettum, Norway.
| | - Ole Marius Ekeberg
- Department for Physical Medicine and Rehabilitation, Helse Fonna Hospital, Stord, Tysevegen 64, Stord Sjukehus HF, 5416, Stord, Norway
| | - Hanna Bjørnsson Hallgren
- Orthopedic Department, Linköping University Hospital, Garnisonsvägen 10, 581 85, Linköping, Sweden
| | - Ingar Heier
- Department for Physical Medicine and Rehabilitation, Vestfold Hospital, Stavern, Kysthospitalveien 61, 3294, Stavern, Norway
| | - Synnøve Kvalheim
- Department for Physical Medicine and Rehabilitation, Oslo University Hospital, P.O.B. 4956, Nydalen, 0424, Oslo, Norway
| | - Jesper Blomquist
- Orthopedic Department, Haraldsplass Deaconess Hospital, P.O.B. 6165, 5892, Bergen, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, 0424, Oslo, Norway
| | - Nils Gunnar Juel
- Department for Physical Medicine and Rehabilitation, Oslo University Hospital, P.O.B. 4956, Nydalen, 0424, Oslo, Norway
| | | | - Jens Ivar Brox
- Department for Physical Medicine and Rehabilitation, Oslo University Hospital, P.O.B. 4956, Nydalen, 0424, Oslo, Norway
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When is elective resection after acute diverticulitis reasonable? Lancet Gastroenterol Hepatol 2017; 2:2-3. [DOI: 10.1016/s2468-1253(16)30112-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
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Savulescu J, Wartolowska K, Carr A. Randomised placebo-controlled trials of surgery: ethical analysis and guidelines. JOURNAL OF MEDICAL ETHICS 2016; 42:776-783. [PMID: 27777269 PMCID: PMC5256399 DOI: 10.1136/medethics-2015-103333] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 09/06/2016] [Accepted: 09/27/2016] [Indexed: 05/03/2023]
Abstract
Use of a placebo control in surgical trials is a divisive issue. We argue that, in principle, placebo controls for surgery are necessary in the same way as for medicine. However, there are important differences between these types of trial, which both increase justification and limit application of surgical studies. We propose that surgical randomised placebo-controlled trials are ethical if certain conditions are fulfilled: (1) the presence of equipoise, defined as a lack of unbiased evidence for efficacy of an intervention; (2) clinically important research question; (3) the risk to patients is minimised and reasonable; (4) there is uncertainty about treatment allocation rather than deception; (5) there is preliminary evidence for efficacy, which justifies a placebo-controlled design; and (6) ideally, the placebo procedure should have some direct benefit to the patient, for example, as a diagnostic tool. Placebo-controlled trials in surgery will most often be justified when surgery is performed to improve function or relieve symptoms and when objective outcomes are not available, while the risk of mortality or significant morbidity is low. In line with medical placebo-controlled trials, the surgical trial (1) should be sufficiently powered and (2) standardised so that its results are valid, (3) consent should be valid, (4) the standard treatment or rescue medication should be provided if possible, and (5) after the trial, the patients should be told which treatment they received and there should be provision for post-trial care if the study may result in long-term negative effects. We comment and contrast our guidelines with those of the American Medical Association.
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Affiliation(s)
- Julian Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, Oxford, UK
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Andy Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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