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Mitchell TK, Popa M, Ashcroft RE, Prasad S, Sharp A, Carnforth C, Turner M, Khalil A, Fenwick N, Leven S, Woolfall K. Balancing key stakeholder priorities and ethical principles to design a trial comparing intervention or expectant management for early-onset selective fetal growth restriction in monochorionic twin pregnancy: FERN qualitative study. BMJ Open 2024; 14:e080488. [PMID: 39122401 PMCID: PMC11331883 DOI: 10.1136/bmjopen-2023-080488] [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: 10/02/2023] [Accepted: 07/16/2024] [Indexed: 08/12/2024] Open
Abstract
OBJECTIVES As part of the FERN feasibility study, this qualitative research aimed to explore parents' and clinicians' views on the acceptability, feasibility and design of a randomised controlled trial (RCT) of active intervention versus expectant management in monochorionic (MC) diamniotic twin pregnancies with early-onset (prior to 24 weeks) selective fetal growth restriction (sFGR). Interventions could include laser treatment or selective termination which could lead to the death or serious disability of one or both twins. DESIGN Qualitative semi-structured interviews with parents and clinicians. Data were analysed using reflexive thematic analysis and considered against the Principles of Biomedical Ethics. PARTICIPANTS AND SETTING We interviewed 19 UK parents experiencing (six mothers, two partners) or had recently experienced (eight mothers, three partners) early-onset sFGR in MC twin pregnancy and 14 specialist clinicians from the UK and Europe. RESULTS Participants viewed the proposed RCT as 'ethically murky' because they believed that the management of sFGR in MC twin pregnancy should be individualised according to the type and severity of sFGR. Clinicians prioritised the gestational age, size, decrease in growth velocity, access to the placental vessels and acceptability of intervention for parents. Discussions and decision-making about selective termination appeared to cause long-term harm (maleficence). The most important outcome for parents and clinicians was 'live birth'. For clinicians, this was the live birth of at least one twin. For parents, this meant the live birth of both twins, even if this meant that their babies had neurodevelopmental impairment or disabilities. CONCLUSIONS All three pregnancy management approaches for sFGR in MC twin pregnancy carry risks and benefits, and the ultimate goal for parents is to receive individualised care to achieve the best possible outcome for both twins. An RCT was not acceptable to parents or clinicians or seen as ethically appropriate. Alternative study designs should be considered to answer this important research question.
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Affiliation(s)
| | - Mariana Popa
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - Smriti Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Andrew Sharp
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
| | - Christine Carnforth
- Clinical Directorate Professional Services, University of Liverpool, Liverpool, UK
| | - Mark Turner
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Natasha Fenwick
- Research and Resources Officer, Twins Trust, London, Hampshire, UK
| | | | - The FERN study team
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
- School of Law, City University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
- Clinical Directorate Professional Services, University of Liverpool, Liverpool, UK
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Research and Resources Officer, Twins Trust, London, Hampshire, UK
- Twins Trust, Woking, Surrey, UK
| | - Kerry Woolfall
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Cornwall N, Woodcock C, Ashworth J, Harrisson SA, Dikomitis L, White S, Helliwell T, Hodgson E, Knaggs R, Pincus T, Santer M, Mallen CD, Jinks C. Acceptability of a proposed practice pharmacist-led review for opioid-treated patients with persistent pain: A qualitative study to inform intervention development. Br J Pain 2024; 18:274-291. [PMID: 38751561 PMCID: PMC11092934 DOI: 10.1177/20494637231221688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Introduction Regular review of patients prescribed opioids for persistent non-cancer pain (PCNP) is recommended but not routinely undertaken. The PROMPPT (Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams) research programme aims to develop and test a pharmacist-led pain review (PROMPPT) to reduce inappropriate opioid use for persistent pain in primary care. This study explored the acceptability of the proposed PROMPPT review to inform early intervention development. Methods Interviews (n = 15) and an online discussion forum (n = 31) with patients prescribed opioids for PCNP and interviews with pharmacists (n = 13), explored acceptability of a proposed PROMPPT review. A prototype PROMPPT review was then tested and refined through 3 iterative cycles of in-practice testing (IPT) (n = 3 practices, n = 3 practice pharmacists, n = 13 patients). Drawing on the Theoretical Framework of Acceptability (TFA), a framework was generated (including a priori TFA constructs) allowing for deductive and inductive thematic analysis to identify aspects of prospective and experienced acceptability. Results Patients felt uncertain about practice pharmacists delivering the proposed PROMPPT review leading to development of content for the invitation letter for IPT (introducing the pharmacist and outlining the aim of the review). After IPT, patients felt that pharmacists were suited to the role as they were knowledgeable and qualified. Pharmacists felt that the proposed reviews would be challenging. Although challenges were experienced during delivery of PROMPPT reviews, pharmacists found that they became easier to deliver with time, practise and experience. Recommendations for optimisations after IPT included development of the training to include examples of challenging consultations. Conclusions Uptake of new healthcare interventions is influenced by perceptions of acceptability. Exploring prospective and experienced acceptability at multiple time points during early intervention development, led to mini-optimisations of the prototype PROMPPT review ahead of a non-randomised feasibility study.
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Affiliation(s)
| | | | - Julie Ashworth
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | - Sarah A Harrisson
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | - Lisa Dikomitis
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, UK
| | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, Staffordshire, UK
| | - Toby Helliwell
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | | | - Roger Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, Clinical Sciences Building, City Hospital, Nottingham, UK
- UK & Primary Integrated Community Services, Nottingham, UK
| | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, UK
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Christian D Mallen
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | - Clare Jinks
- School of Medicine, Keele University, Keele, UK
| | - on behalf of the PROMPPT team
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, UK
- School of Pharmacy and Bioengineering, Keele University, Keele, Staffordshire, UK
- Leek Health Centre, Leek, UK
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, Clinical Sciences Building, City Hospital, Nottingham, UK
- UK & Primary Integrated Community Services, Nottingham, UK
- Department of Psychology, University of Southampton, Southampton, UK
- Primary Care Research Centre, University of Southampton, Southampton, UK
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Deja E, Weeks A, Van Netten C, Gamble C, Meher S, Gyte G, Lavender T, Woolfall K. Questioning approaches to consent in time critical obstetric trials: findings from a mixed-methods study. BMJ Open 2024; 14:e081874. [PMID: 38341214 PMCID: PMC10862288 DOI: 10.1136/bmjopen-2023-081874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/15/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE Trial legislation enables research to be conducted without prior consent (RWPC) in emergency situations, yet this approach has rarely been used in time-critical obstetric trials. This study explored views and experiences of antenatal recruitment and consent and RWPC in an emergency intrapartum randomised clinical trial. DESIGN Embedded, mixed-methods study within a trial, involving questionnaires, recorded recruitment discussions, interviews and focus groups in the first 13 months of trial recruitment (December 2020-January 2022). SETTING COPE is a double-blind randomised controlled trial, comparing the effectiveness of carboprost or oxytocin as first-line treatment of postpartum haemorrhage. PARTICIPANTS Two hundred and eighty-six people (190 women/96 birth partners), linked to 198/380 (52%) COPE recruits participated in the embedded study. Of these, 272 completed a questionnaire (178 women/94 birth partners), 22 were interviewed (19 women/3 birth partners) and 16 consent discussions with 12 women were recorded. Twenty-seven staff took part in three focus groups and nine staff were interviewed. RESULTS Participants recommended that information about the study should be more accessible antenatally for those who wish to be informed. Most women and staff did not think it would be appropriate to seek consent during pregnancy or early labour as it may cause 'unnecessary panic' and lead to research waste, as most women would not become eligible. There was support for the use of RWPC as COPE interventions are used in standard clinical practice and viewed as low risk. Women who were approached about the trial while having a postpartum haemorrhage also supported RWPC as they could not recall research discussions. CONCLUSIONS Findings support the use of RWPC for time-critical interventions, and raise questions about the appropriateness of other commonly used consent pathways, including antenatal consent and verbal assent.
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Affiliation(s)
- Elizabeth Deja
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Andrew Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | | | - Carrol Gamble
- Health Data Science, University of Liverpool, Liverpool, UK
| | | | | | - Tina Lavender
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Antonacci G, Williams A, Smith J, Green L. Study of Whole blood in Frontline Trauma (SWiFT): implementation study protocol. BMJ Open 2024; 14:e078953. [PMID: 38316586 PMCID: PMC11145983 DOI: 10.1136/bmjopen-2023-078953] [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: 08/16/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Uncontrolled bleeding is a major cause of death for patients with major trauma. Current transfusion practices vary, and there is uncertainty about the optimal strategy. Whole blood (WB) transfusion, which contains all components in one bag, is considered potentially advantageous, particularly for resuscitating patients with major bleeding in the prehospital setting. It could potentially improve survival, reduce donor risk and simplify the processes of delivering blood transfusions outside hospitals. However, the evidence supporting the effectiveness and safety of WB compared with the standard separate blood component therapy is limited. A multicentre randomised controlled trial will be conducted, alongside an implementation study, to assess the efficacy, cost-effectiveness and implementation of prehospital WB transfusion in the prehospital environment. The implementation study will focus on evaluating the acceptability and integration of the intervention into clinical settings and on addressing broader contextual factors that may influence its success or failure. METHODS AND ANALYSIS A type 1 effectiveness-implementation hybrid design will be employed. The implementation study will use qualitative methods, encompassing comprehensive interviews and focus groups with operational staff, patients and blood donor representatives. Staff will be purposefully selected to ensure a wide range of perspectives based on their professional background and involvement in the WB pathway. The study design includes: (1) initial assessment of current practice and processes in the WB pathway; (2) qualitative interviews with up to 40 operational staff and (3) five focus groups with staff and donor representatives. Data analysis will be guided by the theoretical lenses of the Normalisation Process Theory and the Theoretical Framework of Acceptability. ETHICS AND DISSEMINATION The study was prospectively registered and approved by the South Central-Oxford C Research Ethics Committee and the Health Research Authority and Health and Care Research Wales. The results will be published in peer-reviewed journals and provided to all relevant stakeholders. TRIAL REGISTRATION NUMBER ISRCTN23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Allison Williams
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jason Smith
- Department of Emergency, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant and Barts Health NHS Trust, London, UK
- Queen Mary University of London Blizard Institute, London, UK
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Brown A, Ferrando-Vivas P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson BH, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan K, Pathan N. Use of selective gut decontamination in critically ill children: PICnIC a pilot RCT and mixed-methods study. Health Technol Assess 2024; 28:1-84. [PMID: 38421007 PMCID: PMC11017160 DOI: 10.3310/hdkv1008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Background Healthcare-associated infections are a major cause of morbidity and mortality in critically ill children. In adults, data suggest the use of selective decontamination of the digestive tract may reduce the incidence of healthcare-associated infections. Selective decontamination of the digestive tract has not been evaluated in the paediatric intensive care unit population. Objectives To determine the feasibility of conducting a multicentre, cluster-randomised controlled trial in critically ill children comparing selective decontamination of the digestive tract with standard infection control. Design Parallel-group pilot cluster-randomised controlled trial with an integrated mixed-methods study. Setting Six paediatric intensive care units in England. Participants Children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 hours were eligible for the PICnIC pilot cluster-randomised controlled trial. During the ecology periods, all children admitted to the paediatric intensive care units were eligible. Parents/legal guardians of recruited patients and healthcare professionals working in paediatric intensive care units were eligible for inclusion in the mixed-methods study. Interventions The interventions in the PICnIC pilot cluster-randomised controlled trial included administration of selective decontamination of the digestive tract as oro-pharyngeal paste and as a suspension given by enteric tube during the period of mechanical ventilation. Main outcome measures The decision as to whether a definitive cluster-randomised controlled trial is feasible is based on multiple outcomes, including (but not limited to): (1) willingness and ability to recruit eligible patients; (2) adherence to the selective decontamination of the digestive tract intervention; (3) acceptability of the definitive cluster-randomised controlled trial; (4) estimation of recruitment rate; and (5) understanding of potential clinical and ecological outcome measures. Results A total of 368 children (85% of all those who were eligible) were enrolled in the PICnIC pilot cluster-randomised controlled trial across six paediatric intensive care units: 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering selective decontamination of the digestive tract, the majority (98%) of children received at least one dose of selective decontamination of the digestive tract, and of these, 68% commenced within the first 6 hours. Consent for the collection of additional swabs was low (44%), though data completeness for potential outcomes, including microbiology data from routine clinical swab testing, was excellent. Recruited children were representative of the wider paediatric intensive care unit population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cluster-randomised controlled trial of 3 children/site/week, based on data from all UK paediatric intensive care units. The proposed trial, including consent and selective decontamination of the digestive tract, was acceptable to parents and staff with adaptations, including training to improve consent and communication, and adaptations to the administration protocol for the paste and ecology monitoring. Clinical outcomes that were considered important included duration of organ failure and hospital stay, healthcare-acquired infections and survival. Limitations The delivery of the pilot cluster-randomised controlled trial was disrupted by the COVID-19 pandemic, which led to slow set-up of sites, and a lack of face-to face training. Conclusions PICnIC's findings indicate that a definitive cluster-randomised controlled trial in selective decontamination of the digestive tract in paediatric intensive care units is feasible with the inclusion modifications, which would need to be included in a definitive cluster-randomised controlled trial to ensure that the efficiency of trial processes is maximised. Future work A definitive trial that incorporates the protocol adaptations and outcomes arising from this study is feasible and should be conducted. Trial registration This trial is registered as ISRCTN40310490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/152/01) and is published in full in Health Technology Assessment; Vol. 28, No. 8. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Alanna Brown
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Mariana Popa
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - John Pappachan
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University of Southampton, Southampton, UK
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Theodore Gouliouris
- Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- Intensive Care Unit, Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - John Myburgh
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Deja E, Donohue C, Semple MG, Woolfall K. Stakeholders' perspectives on clinical trial acceptability and approach to consent within a limited timeframe: a mixed methods study. BMJ Open 2024; 14:e077023. [PMID: 38167280 PMCID: PMC10773389 DOI: 10.1136/bmjopen-2023-077023] [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: 06/23/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES The Bronchiolitis Endotracheal Surfactant Study (BESS) is a randomised controlled trial to determine the efficacy of endo-tracheal surfactant therapy for critically ill infants with bronchiolitis. To explore acceptability of BESS, including approach to consent within a limited time frame, we explored parent and staff experiences of trial involvement in the first two bronchiolitis seasons to inform subsequent trial conduct. DESIGN A mixed-method embedded study involving a site staff survey, questionnaires and interviews with parents approached about BESS. SETTING Fourteen UK paediatric intensive care units. PARTICIPANTS Of the 179 parents of children approached to take part in BESS, 75 parents (of 69 children) took part in the embedded study. Of these, 55/69 (78%) completed a questionnaire, and 15/69 (21%) were interviewed. Thirty-eight staff completed a questionnaire. RESULTS Parents and staff found the trial acceptable. All constructs of the Adapted Theoretical Framework of Acceptability were met. Parents viewed surfactant as being low risk and hoped their child's participation would help others in the future. Although parents supported research without prior consent in studies of time critical interventions, they believed there was sufficient time to consider this trial. Parents recommended that prospective informed consent should continue to be sought for BESS. Many felt that the time between the consent process and intervention being administered took too long and should be 'streamlined' to avoid delays in administration of trial interventions. Staff described how the training and trial processes worked well, yet patients were missed due to lack of staff to deliver the intervention, particularly at weekends. CONCLUSION Parents and staff supported BESS trial and highlighted aspects of the protocol, which should be refined, including a streamlined informed consent process. Findings will be useful to inform proportionate approaches to consent in future paediatric trials where there is a short timeframe for consent discussions. TRIAL REGISTRATION NUMBER ISRCTN11746266.
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Affiliation(s)
- Elizabeth Deja
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Chloe Donohue
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Mitchell TK, Hall NJ, Yardley I, Cole C, Hardy P, King A, Murray D, Nuthall E, Roehr C, Stanbury K, Williams R, Pearce J, Woolfall K. Mixed-methods feasibility study to inform a randomised controlled trial of proton pump inhibitors to reduce strictures following neonatal surgery for oesophageal atresia. BMJ Open 2023; 13:e066070. [PMID: 37080617 PMCID: PMC10124212 DOI: 10.1136/bmjopen-2022-066070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES This mixed-methods feasibility study aimed to explore parents' and medical practitioners' views on the acceptability and design of a clinical trial to determine whether routine prophylactic proton pump inhibitors (PPI) reduce the incidence of anastomotic stricture in infants with oesophageal atresia (OA). DESIGN Semi-structured interviews with UK parents of an infant with OA and an online survey, telephone interviews and focus groups with clinicians. Data were analysed using reflexive thematic analysis and descriptive statistics. PARTICIPANTS AND SETTING We interviewed 18 parents of infants with OA. Fifty-one clinicians (49 surgeons, 2 neonatologists) from 20/25 (80%) units involved in OA repair completed an online survey and 10 took part in 1 of 2 focus groups. Interviews were conducted with two clinicians whose survey responses indicated they had concerns about the trial. OUTCOME MEASURES Parents and clinicians ranked the same top four outcomes ('Severity of anastomotic stricture', 'Incidence of anastomotic stricture', 'Need for treatment of reflux' and 'Presence of symptoms of reflux') as important to measure for the proposed trial. RESULTS All parents and most clinicians found the use, dose and duration of omeprazole as the intervention medication, and the placebo control, as acceptable. Parents stated they would hypothetically consent to their child's participation in the trial. Concerns of a few parents and clinicians about infants suffering with symptomatic reflux, and the impact of this for study retention, appeared to be alleviated through the symptomatic reflux treatment pathway. Hesitant clinician views appeared to change through discussion of parental support for the study and by highlighting existing research that questions current practice of PPI treatment. CONCLUSIONS Our findings indicate that parents and most clinicians view the proposed Treating Oesophageal Atresia with prophylactic proton pump inhibitors to prevent STricture (TOAST) trial to be feasible and acceptable so long as infants can be given PPI if clinicians deem it clinically necessary. This insight into parent and clinician views and concerns will inform pilot phase trial monitoring, staff training and the development of the trial protocol.
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Affiliation(s)
- Tracy Karen Mitchell
- Department of Public Health, Policy and Systems, Faculty of Health and Life Sciences, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Iain Yardley
- Evelina Children's Hospital, Guy's & St. Thomas's NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Christina Cole
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andy King
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Murray
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth Nuthall
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Charles Roehr
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachel Williams
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Faculty of Health and Life Sciences, Institute of Population Health, University of Liverpool, Liverpool, UK
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Krafft HS, Raak CK, Jenetzky E, Zuzak TJ, Längler A, Martin DD. Warming up for a better fever: a randomized pilot study in pediatric oncology. Pilot Feasibility Stud 2022; 8:183. [PMID: 35974359 PMCID: PMC9380316 DOI: 10.1186/s40814-022-01144-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fever in children is a major problem in pediatric oncology. Usual management leads to immediate antibiotic and antipyretic therapy, although there is consensus that antipyretic therapy should not be utilized with the sole aim of reducing body temperature. Increased body temperature during fever appears to be an effective modifier in terms of viral replication and enhanced host defense mechanisms against pathogens. Therefore, it might be beneficial to support febrile patients by applying gentle heat during the onset of fever to help the body to reach its new thermoregulatory set point. METHODS A randomized pilot study over 6 months will be conducted in a pediatric oncology department in an academic hospital in Germany. This study is a preparation for a multicenter clinical trial with two parallel groups concerning the efficacy of heat application vs. treatment as usual. One of the inclusion criteria is body temperatures ≥ 38.0 °C in n = 24 cases of patients receiving chemotherapy aged 18 months to 17 years. The first intervention consists of gentle heat application with hot water bottles at any sign of illness and onset of fever. The aim is to achieve a warm periphery equilibrated to trunk temperature of less than 0.5 °C. The second intervention is the avoidance of antipyretics. The control group receives the standard antipyretic treatment from the participating hospital. The purposes of this pilot study are proof of principle of intervention, evaluation of safety, feasibility, definition of endpoints, and to receive basic data for sample size calculation and needed resources. DISCUSSION The main goal is to improve the care of children with cancer by providing the best possible support for febrile episodes. If fever support by heat reduces discomfort, administration of antipyretics and maybe even antibiotics, this would be an advancement in oncological fever management. This pilot study is intended to provide a basis for a main, multicenter, randomized trial and demonstrate the practicability of heat application in febrile patients in pediatric oncology. TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00028273 . Registered on 14 April 2022.
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Affiliation(s)
- Hanno S. Krafft
- Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Christa K. Raak
- Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Ekkehart Jenetzky
- Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany
| | - Tycho J. Zuzak
- Department of Pediatrics, Gemeinschaftskrankenhaus, Herdecke, Germany
- Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Alfred Längler
- Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Department of Pediatrics, Gemeinschaftskrankenhaus, Herdecke, Germany
| | - David D. Martin
- Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Department of Pediatrics, Eberhard-Karls University Tübingen, Tübingen, Germany
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Brown A, Ferrando P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson B, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan KM, Pathan N. Use of selective gut decontamination in critically ill children: protocol for the Paediatric Intensive Care and Infection Control (PICnIC) pilot study. BMJ Open 2022; 12:e061838. [PMID: 35277414 PMCID: PMC8919465 DOI: 10.1136/bmjopen-2022-061838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. In critically ill adults, there are data that suggest the use of Selective Decontamination of the Digestive tract (SDD), alongside standard infection control measures reduce mortality and the incidence of HCAIs. SDD-enhanced infection control has not been compared directly with standard infection prevention strategies in the Paediatric Intensive Care Unit (PICU) population. The aim of this pilot study is to determine the feasibility of conducting a multicentre cluster randomised controlled trial (cRCT) in critically ill children comparing SDD with standard infection control. METHODS AND ANALYSIS Paediatric Intensive Care and Infection Control is a parallel group pilot cRCT, with integrated mixed-methods study, comparing incorporation of SDD into infection control procedures to standard care. After a 1-week pretrial ecology surveillance period, recruitment to the cRCT will run for a period of 18 weeks, comprising: (1) baseline control period (2) pre, mid and post-trial ecology surveillance periods and (3) intervention period. Six PICUs (in England, UK) will begin with usual care in period 1, then will be randomised 1:1 by the trial statistician using computer-based randomisation, to either continue to deliver usual care or commence delivery of the intervention (SDD) in period 2. Outcomes measures include parent and healthcare professionals' views on trial feasibility, adherence to the SDD intervention, estimation of recruitment rate and understanding of potential patient-centred primary and secondary outcome measures for the definitive trial. The planned recruitment for the cRCT is 324 participants. ETHICS AND DISSEMINATION The trial received favourable ethical opinion from West Midlands-Black Country Research Ethics Committee (reference: 20/WM/0061) and approval from the Health Research Authority (IRAS number: 239324). Informed consent is not required for SDD intervention or anonymised data collection but is sought for investigations as part of the study, any identifiable data collected and monitoring of medical records. Results will be disseminated via publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ISRCTN40310490.
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Affiliation(s)
- Alanna Brown
- Intensive Care National Audit and Research Centre, London, UK
| | - Paloma Ferrando
- Intensive Care National Audit and Research Centre, London, UK
| | - Mariana Popa
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Brian Cuthbertson
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | | | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - John Myburgh
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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