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Gonzalez JT, Lolli L, Veasey RC, Rumbold PLS, Betts JA, Atkinson G, Stevenson EJ. Are there interindividual differences in the reactive hypoglycaemia response to breakfast? A replicate crossover trial. Eur J Nutr 2024:10.1007/s00394-024-03467-y. [PMID: 39231870 DOI: 10.1007/s00394-024-03467-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/01/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Following consumption of a meal, circulating glucose concentrations can rise and then fall briefly below the basal/fasting concentrations. This phenomenon is known as reactive hypoglycaemia but to date no researcher has explored potential inter-individual differences in response to meal consumption. OBJECTIVE We conducted a secondary analysis of existing data to examine inter-individual variability of reactive hypoglycaemia in response to breakfast consumption. METHODS Using a replicate crossover design, 12 healthy, physically active men (age: 18-30 y, body mass index: 22.1 to 28.0 kg⋅m- 2) completed two identical control (continued overnight fasting) and two breakfast (444 kcal; 60% carbohydrate, 17% protein, 23% fat) conditions in randomised sequences. Blood glucose and lactate concentrations, serum insulin and non-esterified fatty acid concentrations, whole-body energy expenditure, carbohydrate and fat oxidation rates, and appetite ratings were determined before and 2 h after the interventions. Inter-individual differences were explored using Pearson's product-moment correlations between the first and second replicates of the fasting-adjusted breakfast response. Within-participant covariate-adjusted linear mixed models and a random-effects meta-analytical approach were used to quantify participant-by-condition interactions. RESULTS Breakfast consumption lowered 2-h blood glucose by 0.44 mmol/L (95%CI: 0.76 to 0.12 mmol/L) and serum NEFA concentrations, whilst increasing blood lactate and serum insulin concentrations (all p < 0.01). Large, positive correlations were observed between the first and second replicates of the fasting-adjusted insulin, lactate, hunger, and satisfaction responses to breakfast consumption (all r > 0.5, 90%CI ranged from 0.03 to 0.91). The participant-by-condition interaction response variability (SD) for serum insulin concentration was 11 pmol/L (95%CI: 5 to 16 pmol/L), which was consistent with the τ-statistic from the random-effects meta-analysis (11.7 pmol/L, 95%CI 7.0 to 22.2 pmol/L) whereas effects were unclear for other outcome variables (e.g., τ-statistic value for glucose: 0 mmol/L, 95%CI 0.0 to 0.5 mmol/L). CONCLUSIONS Despite observing reactive hypoglycaemia at the group level, we were unable to detect any meaningful inter-individual variability of the reactive hypoglycaemia response to breakfast. There was, however, evidence that 2-h insulin responses to breakfast display meaningful inter-individual variability, which may be explained by relative carbohydrate dose ingested and variation in insulin sensitivity of participants.
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Affiliation(s)
- Javier T Gonzalez
- Centre for Nutrition, Exercise and Metabolism, University of Bath, Bath, UK.
- Department for Health, University of Bath, Bath, BA2 7AY, UK.
| | - Lorenzo Lolli
- Department of Sport and Exercise Sciences, Institute of Sport, Manchester Metropolitan University, Manchester, UK
| | - Rachel C Veasey
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Penny L S Rumbold
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - James A Betts
- Centre for Nutrition, Exercise and Metabolism, University of Bath, Bath, UK
- Department for Health, University of Bath, Bath, BA2 7AY, UK
| | - Greg Atkinson
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Emma J Stevenson
- Faculty of Medical Sciences, Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Ryan EG, Gao CX, Grantham KL, Thao LTP, Charles-Nelson A, Bowden R, Herschtal A, Lee KJ, Forbes AB, Heritier S, Phillipou A, Wolfe R. Advancing randomized controlled trial methodologies: The place of innovative trial design in eating disorders research. Int J Eat Disord 2024; 57:1337-1349. [PMID: 38469971 DOI: 10.1002/eat.24187] [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: 11/13/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024]
Abstract
Randomized controlled trials can be used to generate evidence on the efficacy and safety of new treatments in eating disorders research. Many of the trials previously conducted in this area have been deemed to be of low quality, in part due to a number of practical constraints. This article provides an overview of established and more innovative clinical trial designs, accompanied by pertinent examples, to highlight how design choices can enhance flexibility and improve efficiency of both resource allocation and participant involvement. Trial designs include individually randomized, cluster randomized, and designs with randomizations at multiple time points and/or addressing several research questions (master protocol studies). Design features include the use of adaptations and considerations for pragmatic or registry-based trials. The appropriate choice of trial design, together with rigorous trial conduct, reporting and analysis, can establish high-quality evidence to advance knowledge in the field. It is anticipated that this article will provide a broad and contemporary introduction to trial designs and will help researchers make informed trial design choices for improved testing of new interventions in eating disorders. PUBLIC SIGNIFICANCE: There is a paucity of high quality randomized controlled trials that have been conducted in eating disorders, highlighting the need to identify where efficiency gains in trial design may be possible to advance the eating disorder research field. We provide an overview of some key trial designs and features which may offer solutions to practical constraints and increase trial efficiency.
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Affiliation(s)
- Elizabeth G Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Caroline X Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
| | - Kelsey L Grantham
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anaïs Charles-Nelson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rhys Bowden
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alan Herschtal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Phillipou
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
- Department of Mental Health, Austin Health, Melbourne, Victoria, Australia
- Department of Mental Health, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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San Luciano M, Oehrn CR, Wang SS, Tolmie JS, Wiltshire A, Graff RE, Zhu J, Starr PA. Protocol for combined N-of-1 trials to assess cerebellar neurostimulation for movement disorders in children and young adults with dyskinetic cerebral palsy. BMC Neurol 2024; 24:145. [PMID: 38684956 PMCID: PMC11057158 DOI: 10.1186/s12883-024-03633-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] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/09/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Movement and tone disorders in children and young adults with cerebral palsy are a great source of disability. Deep brain stimulation (DBS) of basal ganglia targets has a major role in the treatment of isolated dystonias, but its efficacy in dyskinetic cerebral palsy (DCP) is lower, due to structural basal ganglia and thalamic damage and lack of improvement of comorbid choreoathetosis and spasticity. The cerebellum is an attractive target for DBS in DCP since it is frequently spared from hypoxic ischemic damage, it has a significant role in dystonia network models, and small studies have shown promise of dentate stimulation in improving CP-related movement and tone disorders. METHODS Ten children and young adults with DCP and disabling movement disorders with or without spasticity will undergo bilateral DBS in the dorsal dentate nucleus, with the most distal contact ending in the superior cerebellar peduncle. We will implant Medtronic Percept, a bidirectional neurostimulator that can sense and store brain activity and deliver DBS therapy. The efficacy of cerebellar DBS in improving quality of life and motor outcomes will be tested by a series of N-of-1 clinical trials. Each N-of-1 trial will consist of three blocks, each consisting of one month of effective stimulation and one month of sham stimulation in a random order with weekly motor and quality of life scales as primary and secondary outcomes. In addition, we will characterize abnormal patterns of cerebellar oscillatory activity measured by local field potentials from the intracranial electrodes related to clinical assessments and wearable monitors. Pre- and 12-month postoperative volumetric structural and functional MRI and diffusion tensor imaging will be used to identify candidate imaging markers of baseline disease severity and response to DBS. DISCUSSION Our goal is to test a cerebellar neuromodulation therapy that produces meaningful changes in function and well-being for people with CP, obtain a mechanistic understanding of the underlying brain network disorder, and identify physiological and imaging-based predictors of outcomes useful in planning further studies. TRIAL REGISTRATION ClinicalTrials.gov NCT06122675, first registered November 7, 2023.
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Affiliation(s)
- M San Luciano
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA.
| | - C R Oehrn
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - S S Wang
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - J S Tolmie
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - A Wiltshire
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - R E Graff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - J Zhu
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - P A Starr
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
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Crichton A, Harris K, McGree JM, Nikles J, Anderson PJ, Williams K. Fetal alcohol spectrum disorder and attention deficit hyperactivity disorder stimulant trial in children: an N-of-1 pilot trial to compare stimulant to placebo (FASST): protocol. BMJ Open 2024; 14:e071266. [PMID: 38631835 PMCID: PMC11029357 DOI: 10.1136/bmjopen-2022-071266] [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: 12/22/2022] [Accepted: 08/21/2023] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Fetal alcohol spectrum disorder (FASD) is a neurodevelopmental disorder caused by alcohol exposure during pregnancy. FASD is associated with neurodevelopmental deviations, and 50%-94% of children with FASD meet the Diagnostic and Statistical Manual of Mental Disorders-fifth edition diagnostic criteria for attention deficit hyperactivity disorder (ADHD). There is a paucity of evidence around medication efficacy for ADHD symptoms in children with FASD. This series of N-of-1 trials aims to provide pilot data on the feasibility of conducting N-of-1 trials in children with FASD and ADHD. METHODS AND ANALYSIS A pilot N-of-1 randomised trial design with 20 cycles of stimulant and placebo (four cycles of 2-week duration) for each child will be conducted (n=20) in Melbourne, Australia.Feasibility and tolerability will be assessed using recruitment and retention rates, protocol adherence, adverse events and parent ratings of side effects. Each child's treatment effect will be determined by analysing teacher ADHD ratings across stimulant and placebo conditions (Wilcoxon rank). N-of-1 data will be aggregated to provide an estimate of the cohort treatment effect as well as individual-level treatment effects. We will assess the sample size and number of cycles required for a future trial. Potential mediating factors will be explored to identify variables that might be associated with treatment response variability. ETHICS AND DISSEMINATION The study was approved by the Hospital and Health Service Human Research Ethics Committee (HREC/74678/MonH-2021-269029), Monash (protocol V6, 25 June 2023).Individual outcome data will be summarised and provided to participating carers and practitioners to enhance care. Group-level findings will be presented at a local workshop to engage stakeholders. Findings will be presented at national and international conferences and published in peer-reviewed journals. All results will be reported so that they can be used to inform prior information for future trials. TRIAL REGISTRATION NUMBER NCT04968522.
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Affiliation(s)
- Alison Crichton
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Katrina Harris
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Developmental and Community Paediatrics, Monash Health, Clayton, Victoria, Australia
| | - James M McGree
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jane Nikles
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Peter J Anderson
- Monash Institute of Cognitive and Clinical Neuroscience, Monash University, Clayton, Victoria, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
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San Luciano M, Oehrn CR, Wang SS, Tolmie JS, Wiltshire A, Graff RE, Zhu J, Starr PA. Protocol for combined N-of-1 trials to assess cerebellar neurostimulation for movement disorders in children and young adults with dyskinetic cerebral palsy. RESEARCH SQUARE 2024:rs.3.rs-4077387. [PMID: 38645256 PMCID: PMC11030503 DOI: 10.21203/rs.3.rs-4077387/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Movement and tone disorders in children and young adults with cerebral palsy are a great source of disability. Deep brain stimulation (DBS) of basal ganglia targets has a major role in the treatment of isolated dystonias, but its efficacy in dyskinetic cerebral palsy (DCP) is lower, due to structural basal ganglia and thalamic damage and lack of improvement of comorbid choreoathetosis and spasticity. The cerebellum is an attractive target for DBS in DCP since it is frequently spared from hypoxic ischemic damage, it has a significant role in dystonia network models, and small studies have shown promise of dentate stimulation in improving CP-related movement and tone disorders. Methods Ten children and young adults with DCP and disabling movement disorders with or without spasticity will undergo bilateral DBS in the dorsal dentate nucleus, with the most distal contact ending in the superior cerebellar peduncle. We will implant Medtronic Percept, a bidirectional neurostimulator that can sense and store brain activity and deliver DBS therapy. The efficacy of cerebellar DBS in improving quality of life and motor outcomes will be tested by a series of N-of-1 clinical trials. Each N-of-1 trial will consist of three blocks, each consisting of one month of effective stimulation and one month of sham stimulation in a random order with weekly motor and quality of life scales as primary and secondary outcomes. In addition, we will characterize abnormal patterns of cerebellar oscillatory activity measured by local field potentials from the intracranial electrodes related to clinical assessments and wearable monitors. Pre- and 12-month postoperative volumetric structural and functional MRI and diffusion tensor imaging will be used to identify candidate imaging markers of baseline disease severity and response to DBS. Discussion Our goal is to test a cerebellar neuromodulation therapy that produces meaningful changes in function and well-being for people with CP, obtain a mechanistic understanding of the underlying brain network disorder, and identify physiological and imaging-based predictors of outcomes useful in planning further studies. Trial registration ClinicalTrials.gov NCT06122675, first registered November 7, 2023.
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Affiliation(s)
- Marta San Luciano
- University of California, San Francisco, Weill Institute for Neurosciences
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Batley P, Thamaran M, Hedges LV. ABkPowerCalculator: An App to Compute Power for Balanced (AB) k Single Case Experimental Designs. MULTIVARIATE BEHAVIORAL RESEARCH 2024; 59:406-410. [PMID: 37847706 DOI: 10.1080/00273171.2023.2261229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Single case experimental designs are an important research design in behavioral and medical research. Although there are design standards prescribed by the What Works Clearinghouse for single case experimental designs, these standards do not include statistically derived power computations. Recently we derived the equations for computing power for (AB)k designs. However, these computations and the software code in R may not be accessible to applied researchers who are most likely to want to compute power for their studies. Therefore, we have developed an (AB)k power calculator Shiny App (https://abkpowercalculator.shinyapps.io/ABkpowercalculator/) that researchers can use with no software training. These power computations assume that the researcher would be interested in fitting multilevel models with autocorrelations or conduct similar analyses. The purpose of this software contribution is to briefly explain how power is derived for balanced (AB)k designs and to elaborate on how to use the Shiny App. The app works well on not just computers but mobile phones without installing the R program. We believe this can be a valuable tool for practitioners and applied researchers who want to plan their single case studies with sufficient power to detect appropriate effect sizes.
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Senn S. The analysis of continuous data from n-of-1 trials using paired cycles: a simple tutorial. Trials 2024; 25:128. [PMID: 38365817 PMCID: PMC10870460 DOI: 10.1186/s13063-024-07964-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/01/2024] [Indexed: 02/18/2024] Open
Abstract
N-of-1 trials are defined and the popular paired cycle design is introduced, together with an explanation as to how suitable sequences may be constructed.Various approaches to analysing such trials are explained and illustrated using a simulated data set. It is explained how choosing an appropriate analysis depends on the question one wishes to answer. It is also shown that for a given question, various equivalent approaches to analysis can be found, a fact which may be exploited to expand the possible software routines that may be used.Sets of N-of-1 trials are analogous to sets of parallel group trials. This means that software for carrying out meta-analysis can be used to combine results from N-of-1 trials. In doing so, it is necessary to make one important change, however. Because degrees of freedom for estimating variances for individual subjects will be scarce, it is advisable to estimate local standard errors using pooled variances. How this may be done is explained and fixed and random effect approaches to combining results are illustrated.
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Müller AR, den Hollander B, van de Ven PM, Roes KCB, Geertjens L, Bruining H, van Karnebeek CDM, Jansen FE, de Wit MCY, Ten Hoopen LW, Rietman AB, Dierckx B, Wijburg FA, Boot E, Brands MMG, van Eeghen AM. Cannabidiol (Epidyolex®) for severe behavioral manifestations in patients with tuberous sclerosis complex, mucopolysaccharidosis type III and fragile X syndrome: protocol for a series of randomized, placebo-controlled N-of-1 trials. BMC Psychiatry 2024; 24:23. [PMID: 38177999 PMCID: PMC10768432 DOI: 10.1186/s12888-023-05422-3] [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: 07/27/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Many rare genetic neurodevelopmental disorders (RGNDs) are characterized by intellectual disability (ID), severe cognitive and behavioral impairments, potentially diagnosed as a comorbid autism spectrum disorder or attention-deficit hyperactivity disorder. Quality of life is often impaired due to irritability, aggression and self-injurious behavior, generally refractory to standard therapies. There are indications from previous (case) studies and patient reporting that cannabidiol (CBD) may be an effective treatment for severe behavioral manifestations in RGNDs. However, clear evidence is lacking and interventional research is challenging due to the rarity as well as the heterogeneity within and between disease groups and interindividual differences in treatment response. Our objective is to examine the effectiveness of CBD on severe behavioral manifestations in three RGNDs, including Tuberous Sclerosis Complex (TSC), mucopolysaccharidosis type III (MPS III), and Fragile X syndrome (FXS), using an innovative trial design. METHODS We aim to conduct placebo-controlled, double-blind, block-randomized, multiple crossover N-of-1 studies with oral CBD (twice daily) in 30 patients (aged ≥ 6 years) with confirmed TSC, MPS III or FXS and severe behavioral manifestations. The treatment is oral CBD up to a maximum of 25 mg/kg/day, twice daily. The primary outcome measure is the subscale irritability of the Aberrant Behavior Checklist. Secondary outcome measures include (personalized) patient-reported outcome measures with regard to behavioral and psychiatric outcomes, disease-specific outcome measures, parental stress, seizure frequency, and adverse effects of CBD. Questionnaires will be completed and study medication will be taken at the participants' natural setting. Individual treatment effects will be determined based on summary statistics. A mixed model analysis will be applied for analyzing the effectiveness of the intervention per disorder and across disorders combining data from the individual N-of-1 trials. DISCUSSION These N-of-1 trials address an unmet medical need and will provide information on the effectiveness of CBD for severe behavioral manifestations in RGNDs, potentially generating generalizable knowledge at an individual-, disorder- and RGND population level. TRIAL REGISTRATION EudraCT: 2021-003250-23, registered 25 August 2022, https://www.clinicaltrialsregister.eu/ctr-search/trial/2021-003250-23/NL .
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Affiliation(s)
- A R Müller
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - B den Hollander
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Geertjens
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
| | - H Bruining
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
- Levvel, Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - C D M van Karnebeek
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
- Department of Human Genetics, Amsterdam UMC, Amsterdam, The Netherlands
| | - F E Jansen
- Department of Pediatric Neurology, Brain, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Y de Wit
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L W Ten Hoopen
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A B Rietman
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B Dierckx
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - E Boot
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- The Dalglish Family 22Q Clinic, Toronto, ON, Canada
- Department of Psychiatry & Neuropsychology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M M G Brands
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - A M van Eeghen
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- 's Heeren Loo Care Group, Amersfoort, The Netherlands.
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands.
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Shen T, Thackray AE, King JA, Alotaibi TF, Alanazi TM, Willis SA, Roberts MJ, Lolli L, Atkinson G, Stensel DJ. Are There Interindividual Responses of Cardiovascular Disease Risk Markers to Acute Exercise? A Replicate Crossover Trial. Med Sci Sports Exerc 2024; 56:63-72. [PMID: 37703030 DOI: 10.1249/mss.0000000000003283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
PURPOSE Using a replicated crossover design, we quantified the response heterogeneity of postprandial cardiovascular disease risk marker responses to acute exercise. METHODS Twenty men (mean (SD) age, 26 (6) yr; body mass index, 23.9 (2.4) kg·m -2 ) completed four 2-d conditions (two control, two exercise) in randomized orders. On days 1 and 2, participants rested and consumed two high-fat meals over 9 h. Participants ran for 60 min (61 (7)% of peak oxygen uptake) on day 1 (6.5 to 7.5 h) of both exercise conditions. Time-averaged total area under the curve (TAUC) for triacylglycerol, glucose, and insulin were calculated from 11 venous blood samples on day 2. Arterial stiffness and blood pressure responses were calculated from measurements at baseline on day 1 and at 2.5 h on day 2. Consistency of individual differences was explored by correlating the two replicates of control-adjusted exercise responses for each outcome. Within-participant covariate-adjusted linear mixed models quantified participant-by-condition interactions and individual response SDs. RESULTS Acute exercise reduced mean TAUC-triacylglycerol (-0.27 mmol·L -1 ·h; Cohen's d = 0.29, P = 0.017) and TAUC-insulin (-25 pmol·L -1 ·h; Cohen's d = 0.35, P = 0.022) versus control, but led to negligible changes in TAUC-glucose and the vascular outcomes (Cohen's d ≤ 0.36, P ≥ 0.106). Small-to-moderate, but nonsignificant, correlations were observed between the two response replicates ( r = -0.42 to 0.15, P ≥ 0.066). We did not detect any individual response heterogeneity. All participant-by-condition interactions were P ≥ 0.137, and all individual response SDs were small with wide 95% confidence intervals overlapping zero. CONCLUSIONS Large trial-to-trial within-subject variability inhibited detection of consistent interindividual variability in postprandial metabolic and vascular responses to acute exercise.
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Affiliation(s)
| | | | | | | | | | | | | | - Lorenzo Lolli
- Department of Sport and Exercise Sciences, Institute of Sport, Manchester Metropolitan University, Manchester, UNITED KINGDOM
| | - Greg Atkinson
- School of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UNITED KINGDOM
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den Hollander B, Rothuizen-Lindenschot M, Geertjens L, Vaz FM, Brands MM, Le HL, van Eeghen AM, van de Ven PM, Cornel MC, Jacobs BA, Bruining H, van Karnebeek CD. Effectiveness of L-serine supplementation in children with a GRIN2B loss-of-function mutation: Rationale and protocol for single patient (n-of-1) multiple cross-over trials. Contemp Clin Trials Commun 2023; 36:101233. [PMID: 38144875 PMCID: PMC10746402 DOI: 10.1016/j.conctc.2023.101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/20/2023] [Accepted: 11/12/2023] [Indexed: 12/26/2023] Open
Abstract
Rationale Loss-of-function (LoF) mutations in GRIN2B result in neurologic abnormalities due to N-methyl-D-aspartate receptor (NMDAR) dysfunction. Affected persons present with various symptoms, including intellectual developmental disability (IDD), hypotonia, communication deficits, motor impairment, complex behavior, seizures, sleep disorders and gastrointestinal disturbance. Recently, in vitro experiments showed that D-serine mitigates function to GluN2B (mutation)-containing NMDARs. 11 previous case reports are published on (experimental) L-serine treatment of patients between 1.5 and 12 years old with GRIN2B missense or null mutations, some of whom showed notable improvement in motor and cognitive performance, communication, behavior and abnormalities on electro encephalography (EEG). Our objective is to further evaluate the effectiveness of L-serine for GRIN2B-related neurodevelopmental disorder (GRIN2B-NDD), using an n-of-1 trial design, increasing the level of evidence. Methods/design These n-of-1 trials, consisting of 2 cycles of 6 months, will be performed to evaluate the effect of L-serine compared to placebo in 4 patients with a GRIN2B LoF mutation. The aggregation of multiple n-of-1 trials will provide an estimate of the average treatment effects.The primary outcome is the Perceive-Recall-Plan-Perform of Task Analysis, assessing developmental skills. Secondary outcomes include Goal Attainment Scaling, seizure log books, EEGs, sleep log books, the irritability subscale of the Aberrant Behavior Checklist, the Bristol Stool Scale and the Pediatric Quality of Life Inventory. Conclusion This study employs an innovative methodological approach to evaluate the effectiveness of L-serine for patients with a GRIN2B LoF mutation. The results will establish a foundation for implementing L-serine as a disease-modifying treatment in GRIN2B-NDD.
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Affiliation(s)
- Bibiche den Hollander
- Amsterdam UMC Location University of Amsterdam, Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
- Emma Personalized Medicine Center, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, the Netherlands
| | | | - Lisa Geertjens
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Child and Adolescent Psychiatry and Psychosocial Care, Emma Children's Hospital, Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam UMC Location University of Amsterdam, N=You Neurodevelopmental Precision Center, Amsterdam Neuroscience, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Frédéric M. Vaz
- United for Metabolic Diseases, Amsterdam, the Netherlands
- Amsterdam UMC Location University of Amsterdam, Department of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Inborn Errors of Metabolism, Amsterdam, the Netherlands
- Amsterdam UMC Location University of Amsterdam, Department of Core Facility Metabolomics, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marion M. Brands
- Amsterdam UMC Location University of Amsterdam, Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
- Emma Personalized Medicine Center, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, the Netherlands
| | - Hoang Lan Le
- Amsterdam UMC Location University of Amsterdam, Department of Hospital Pharmacy, Meibergdreef 9, Amsterdam, the Netherlands
- Medicine for Society, Platform at Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, the Netherlands
| | - Agnies M. van Eeghen
- Emma Personalized Medicine Center, Amsterdam UMC, Amsterdam, the Netherlands
- Advisium, ‘s Heerlen Loo Zorggroep, Amersfoort, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Emma Children’s Hospital, Amsterdam Public Health Research Institute, Methodology and Mental Health and Personalized Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Emma Children’s Hospital, Amsterdam Reproduction & Development, Child Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Peter M. van de Ven
- University Medical Center Utrecht, Department of Data Science and Biostatistics, Julius Center for Health Sciences and Primary Care, Heidelberglaan 100, Utrecht, the Netherlands
| | - Martina C. Cornel
- Emma Personalized Medicine Center, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit van Amsterdam, Department of Human Genetics, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Bart A.W. Jacobs
- Medicine for Society, Platform at Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, the Netherlands
- Antoni van Leeuwenhoek, Department of Pharmacy and Clinical Pharmacology, Plesmanlaan 121, Amsterdam, the Netherlands
| | - Hilgo Bruining
- Emma Personalized Medicine Center, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Child and Adolescent Psychiatry and Psychosocial Care, Emma Children's Hospital, Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam UMC Location University of Amsterdam, N=You Neurodevelopmental Precision Center, Amsterdam Neuroscience, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Clara D. van Karnebeek
- Amsterdam UMC Location University of Amsterdam, Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
- Emma Personalized Medicine Center, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit van Amsterdam, Department of Human Genetics, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
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11
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Margaritelis NV. Personalized redox biology: Designs and concepts. Free Radic Biol Med 2023; 208:112-125. [PMID: 37541453 DOI: 10.1016/j.freeradbiomed.2023.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/19/2023] [Accepted: 08/01/2023] [Indexed: 08/06/2023]
Abstract
Personalized interventions are regarded as a next-generation approach in almost all fields of biomedicine, such as clinical medicine, exercise, nutrition and pharmacology. At the same time, an increasing body of evidence indicates that redox processes regulate, at least in part, multiple aspects of human physiology and pathology. As a result, the idea of applying personalized redox treatments to improve their efficacy has gained popularity among researchers in recent years. The aim of the present primer-style review was to highlight some crucial yet underappreciated methodological, statistical, and interpretative concepts within the redox biology literature, while also providing a physiology-oriented perspective on personalized redox biology. The topics addressed are: (i) the critical issue of investigating the potential existence of inter-individual variability; (ii) the importance of distinguishing a genuine and consistent response of a subject from a chance finding; (iii) the challenge of accurately quantifying the effect of a redox treatment when dealing with 'extreme' groups due to mathematical coupling and regression to the mean; and (iv) research designs and analyses that have been implemented in other fields, and can be reframed and exploited in a redox biology context.
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Affiliation(s)
- Nikos V Margaritelis
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Agios Ioannis, 62122, Serres, Greece.
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12
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Gärtner T, Schneider J, Arnrich B, Konigorski S. Comparison of Bayesian Networks, G-estimation and linear models to estimate causal treatment effects in aggregated N-of-1 trials with carry-over effects. BMC Med Res Methodol 2023; 23:191. [PMID: 37605171 PMCID: PMC10440905 DOI: 10.1186/s12874-023-02012-5] [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: 07/13/2022] [Accepted: 08/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND The aggregation of a series of N-of-1 trials presents an innovative and efficient study design, as an alternative to traditional randomized clinical trials. Challenges for the statistical analysis arise when there is carry-over or complex dependencies of the treatment effect of interest. METHODS In this study, we evaluate and compare methods for the analysis of aggregated N-of-1 trials in different scenarios with carry-over and complex dependencies of treatment effects on covariates. For this, we simulate data of a series of N-of-1 trials for Chronic Nonspecific Low Back Pain based on assumed causal relationships parameterized by directed acyclic graphs. In addition to existing statistical methods such as regression models, Bayesian Networks, and G-estimation, we introduce a carry-over adjusted parametric model (COAPM). RESULTS The results show that all evaluated existing models have a good performance when there is no carry-over and no treatment dependence. When there is carry-over, COAPM yields unbiased and more efficient estimates while all other methods show some bias in the estimation. When there is known treatment dependence, all approaches that are capable to model it yield unbiased estimates. Finally, the efficiency of all methods decreases slightly when there are missing values, and the bias in the estimates can also increase. CONCLUSIONS This study presents a systematic evaluation of existing and novel approaches for the statistical analysis of a series of N-of-1 trials. We derive practical recommendations which methods may be best in which scenarios.
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Affiliation(s)
- Thomas Gärtner
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany.
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany.
| | - Juliana Schneider
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany
| | - Bert Arnrich
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany
| | - Stefan Konigorski
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany.
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany.
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, USA.
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13
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Zhao Y, Xie W, Wu X, Li X, Guo J, Cao Q, Liang J, Chen XL, Zhao W, Sun F, Li H, Luo W, Li Y. Anal fistulotomy with one-stage shaped skin grafting for intersphincter anal fistulas: study protocol on a multicentre randomised controlled trial. Trials 2023; 24:470. [PMID: 37481545 PMCID: PMC10363312 DOI: 10.1186/s13063-023-07495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 07/04/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Anal fistulas are mainly treated via surgery. They can be difficult to treat without surgical intervention. Numerous procedures, such as fistulectomy and fistulotomy, are performed to treat anal fistulas and achieve good effects. However, the wounds created through fistulectomy and fistulotomy take a long time to heal. Therefore, a multicentre randomised controlled trial (RCT) is proposed to study the efficacy of one-stage shaped skin grafting at the surgical wound to heal low simple intersphincter anal fistulas. METHODS This study is a multicentre, hospital-based RCT. It will be performed at three hospitals. A total of 104 patients with low simple intersphincter anal fistulas who meet the inclusion criteria will be included in this trial and will be allocated randomly to two groups (test and control groups). The patients in the test group will receive one-stage anal fistulotomy surgery combined with shaped skin grafting, and those in the control group will undergo anal fistulotomy only. All the operations will be performed by attending colorectal surgeons or surgeons of a higher level. Effectiveness and safety indicators will be observed, recorded and analysed. DISCUSSION Anal fistulotomy can heal low simple intersphincter anal fistulas effectively and safely with a low recurrence rate. Skin grafts promote wound epithelisation significantly. We believe that skin grafting can treat low simple intersphincter fistulas with a short healing time. TRIAL REGISTRATION Chinese Clinical Trial Register, ChiCTR2000039174. Registered on 28 October 2020.
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Affiliation(s)
- Yongchang Zhao
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Wei Xie
- Department of Gastrointestinal Surgery, Guangzhou Panyu Hexian Memorial Hospital, Guangzhou, 510000, China
| | - Xiaoshuo Wu
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Xiaolan Li
- Department of Anorectal Surgery, Dongguan People's Hospital, Dongguan, 523000, China
| | - Jinyan Guo
- Department of Anorectal Surgery, Jiangmen Wuyi Hospital of Chinese Medicine, Jiangmen, 529000, China
| | - Qiurui Cao
- Department of Anorectal Surgery, Jiangmen Wuyi Hospital of Chinese Medicine, Jiangmen, 529000, China
| | - Jiadi Liang
- Department of Anorectal Surgery, Dongguan People's Hospital, Dongguan, 523000, China
| | - Xin-Lin Chen
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Wentao Zhao
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Feng Sun
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Hongjie Li
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Weimin Luo
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Yuying Li
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China.
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14
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Klotz R, Emile G, Daviet JC, De Sèze M, Godet J, Urbinelli R, Krasny-Pacini A. Daily socket comfort in transtibial amputee with a vacuum-assisted suspension system: study protocol of a randomized, multicenter, double-blind multiple N-of-1 trial. BMC Sports Sci Med Rehabil 2023; 15:85. [PMID: 37452356 PMCID: PMC10347726 DOI: 10.1186/s13102-023-00694-4] [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] [Received: 08/31/2022] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The main aim of this paper is to present the feasibility of rigorously designed multiple N-of-1 design in prosthetics research. While research of adequate power and high quality is often lacking in rehabilitation, N-of-1 trials can offer a feasible alternative to randomized controlled group trials, both increasing design power at group level and allowing a rigorous, statistically confirmed evaluation of effectiveness at a single patient level. The paper presents a multiple N-of-1 trial protocol, which aim is to evaluate the effectiveness of Unity, a prosthetic add-on suspension system for amputees, on patient-reported comfort during daily activities (main outcome measure), prosthesis wearing time, perception of limb-prosthesis fitting and stump volume and functional walking parameters. METHODS Multicenter, randomized, prospective, double-blind multiple N-of-1 trial using an introduction/withdrawal design alternating Unity connected/disconnected phases of randomized length on twenty patients with unilateral transtibial amputation. The primary outcome measure is the Prosthetic Socket Comfort Score (SCS), a validated measure of comfort, administered daily by an phone app designed for the study. Secondary outcomes measures will be collected during the 50 days period of the N-of-1 trial: (1) by the same app, daily for patient-reported limb-prosthesis fitting, stump volume variation, and daily wearing time of the prosthesis; (2) by a pedometer for the number of steps per day; (3) by blind assessors in the rehabilitation center during adjustment visits for functional walking parameter (L-Test, 6-minute walk test), and by the patient for the QUEST, and ABC-S. Effectiveness of the Unity system regarding SCS and daily secondary outcome measures will be tested by randomization test. The secondary outcome measures assessed during visits in the rehabilitation center will be analyzed by Non Overlap of All pairs. An estimate of the effect on the amputee population will be generated by aggregating each individual clinical trial (N-of-1 trial) by Hierarchical Bayesian methods. DISCUSSION This study protocol was designed to answer the question "which device is best for THIS patient" and to conclude at a group level on the effectiveness of a new devic, using a Multiple N-of-1 trial, which is promising but underused in prosthetics research so far. TRIAL REGISTRATION N° ID-RCB 2020-A01309-30 Clintrial.gov : NCT04804150 - Retrospectively registered March 20th 2021.
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Affiliation(s)
- Rémi Klotz
- La Tour de Gassies Centre for Physical Medicine and Rehabilitation, UGECAM, Rue de la Tour de Gassies, Bruges, 33523, France
| | - Guilhem Emile
- Department of Physical and Rehabilitation Medicine, Centre Hospitalier d'Arcachon, Avenue Jean Hameau, 33260, La Teste de Buch, France
| | - Jean-Christophe Daviet
- Department of Physical and Rehabilitation Medicine, Limoges University, Jean Rebeyrol Hospital, Avenue du Buisson, 87170, Limoges, France
| | - Mathieu De Sèze
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, University of Bordeaux, EA4136, Bordeaux, France
| | - Julien Godet
- Clinical Research Methods Group, Laboratory of Bioimaging and Pathologies, UMR CNRS 7021, University Hospitals of Strasbourg, Illkirch, Strasbourg, France
| | | | - Agata Krasny-Pacini
- Department of Physical and Rehabilitation Medicine, UF 4372, CHU de Strasbourg, Institut Universitaire de Réadaptation Clémenceau, 45 Boulevard Clémenceau, Strasbourg, 67000, France
- Department of Psychiatry, Hôpital civil, INSERM 1114, Strasbourg University Hospital, Strasbourg, France
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15
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Nonlinear Dynamic Measures of Walking in Healthy Older Adults: A Systematic Scoping Review. SENSORS 2022; 22:s22124408. [PMID: 35746188 PMCID: PMC9228430 DOI: 10.3390/s22124408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 02/01/2023]
Abstract
Background: Maintaining a healthy gait into old age is key to preserving the quality of life and reducing the risk of falling. Nonlinear dynamic analyses (NDAs) are a promising method of identifying characteristics of people who are at risk of falling based on their movement patterns. However, there is a range of NDA measures reported in the literature. The aim of this review was to summarise the variety, characteristics and range of the nonlinear dynamic measurements used to distinguish the gait kinematics of healthy older adults and older adults at risk of falling. Methods: Medline Ovid and Web of Science databases were searched. Forty-six papers were included for full-text review. Data extracted included participant and study design characteristics, fall risk assessment tools, analytical protocols and key results. Results: Among all nonlinear dynamic measures, Lyapunov Exponent (LyE) was most common, followed by entropy and then Fouquet Multipliers (FMs) measures. LyE and Multiscale Entropy (MSE) measures distinguished between older and younger adults and fall-prone versus non-fall-prone older adults. FMs were a less sensitive measure for studying changes in older adults’ gait. Methodology and data analysis procedures for estimating nonlinear dynamic measures differed greatly between studies and are a potential source of variability in cross-study comparisons and in generating reference values. Conclusion: Future studies should develop a standard procedure to apply and estimate LyE and entropy to quantify gait characteristics. This will enable the development of reference values in estimating the risk of falling.
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16
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Weng S, Li J, Chen B, He L, Zhong Z, Huang L, Zhang S, Liu F, Jiang Q. Effectiveness of modified Buzhong Yiqi decoction in treating myasthenia gravis: study protocol for a series of N-of-1 trials. Trials 2022; 23:365. [PMID: 35477531 PMCID: PMC9044679 DOI: 10.1186/s13063-022-06287-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Myasthenia gravis (MG) is an acquired autoimmune disease with high heterogeneity. The disease is chronic, relapsing repeatedly and progressive with acute exacerbation occasionally. Although the treatment of MG has developed, it is still unsatisfactory and has some unexpected side effects. Traditional Chinese medicine (TCM) has shown great potential in MG treatment, including relief of muscle weakness syndrome, improvement of patient’s quality of life, and reduction of side effects of western medicine. The purpose of this study is to evaluate the effectiveness of modified Buzhong Yiqi decoction (MBYD) as an add-on therapy for MG through a small series of N-of-1 trials. Methods Single-centre, randomized, double-blind, 3 crossover N-of-1 trials will be conducted to enroll patients with MG diagnosed as spleen-stomach deficiency syndrome or spleen-kidney deficiency syndrome in TCM. Each N-of-1 trial has 3 cycles of two 4-week periods containing the MBYD period and placebo period. The wash-out interval of 1 week is prior to switching each period. Primary outcome: quantitative myasthenia gravis (QMG). Secondary outcomes: the following scales: myasthenia gravis composite (MGC), myasthenia gravis activities of daily living profile (MG-ADL), myasthenia gravis quality of life (MG-QOL); the level of CD4+FoxP3+Treg cells and cytokines (IL-4, IL-17A, INF-γ, TGF-β) in the peripheral blood; the alterations of the composition of gut microbiota; reduction of the side effects of western medicine. Discussion Used by WinBUGS software, we will conduct a hierarchical Bayesian statistical method to analyze the efficacy of MBYD in treating MG in individuals and populations. Some confounding variables such as TCM syndrome type and potential carryover effect of TCM will be introduced into the hierarchical Bayesian statistical method to improve the sensitivity and applicability of the trials, and the use of prior available information within the analysis may improve the sensitivity of the results of a series of N-of-1 trials, from both the individual and population level to study the efficacy of TCM syndrome differentiation. We assumed that this study would reveal that MBYD is effective for MG and provide robust evidence of the efficacy of TCM to treat MG. Trial registration Chinese Clinical Trial Register, ID: ChiCTR2000040477, registration on 29 November 2020.
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Affiliation(s)
- Senhui Weng
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Lingnan Medical Research Center of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jinghao Li
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Benshu Chen
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Long He
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Lingnan Medical Research Center of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhuotai Zhong
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Lingnan Medical Research Center of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Linwen Huang
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shijing Zhang
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fengbin Liu
- Lingnan Medical Research Center of Guangzhou University of Chinese Medicine, Guangzhou, China. .,Department of Gastroenterology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China. .,Baiyun Hospital of the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Qilong Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
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17
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Müller S, van Oosterhout A, Bervoets C, Christen M, Martínez-Álvarez R, Bittlinger M. Concerns About Psychiatric Neurosurgery and How They Can Be Overcome: Recommendations for Responsible Research. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09485-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Background
Psychiatric neurosurgery is experiencing a revival. Beside deep brain stimulation (DBS), several ablative neurosurgical procedures are currently in use. Each approach has a different profile of advantages and disadvantages. However, many psychiatrists, ethicists, and laypeople are sceptical about psychiatric neurosurgery.
Methods
We identify the main concerns against psychiatric neurosurgery, and discuss the extent to which they are justified and how they might be overcome. We review the evidence for the effectiveness, efficacy and safety of each approach, and discuss how this could be improved. We analyse whether and, if so, how randomised controlled trials (RCTs) can be used in the different approaches, and what alternatives are available if conducting RCTs is impossible for practical or ethical reasons. Specifically, we analyse the problem of failed RCTs after promising open-label studies.
Results
The main concerns are: (i) reservations based on historical psychosurgery, (ii) concerns about personality changes, (iii) concerns regarding localised interventions, and (iv) scepticism due to the lack of scientific evidence. Given the need for effective therapies for treatment-refractory psychiatric disorders and preliminary evidence for the effectiveness of psychiatric neurosurgery, further research is warranted and necessary. Since psychiatric neurosurgery has the potential to modify personality traits, it should be held to the highest ethical and scientific standards.
Conclusions
Psychiatric neurosurgery procedures with preliminary evidence for efficacy and an acceptable risk–benefit profile include DBS and micro- or radiosurgical anterior capsulotomy for intractable obsessive–compulsive disorder. These methods may be considered for individual treatment attempts, but multi-centre RCTs are necessary to provide reliable evidence.
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18
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He W, Cui Z, Chen Y, Wang F, Li F. Status of N-of-1 Trials in Chronic Pain Management: A Narrative Review. Pain Ther 2021; 10:1013-1028. [PMID: 34528159 PMCID: PMC8586287 DOI: 10.1007/s40122-021-00314-4] [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: 07/11/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022] Open
Abstract
N-of-1 trials are randomized controlled clinical trials conducted exclusively on a single patient. The ultimate aim of N-of-1 trials is to optimize a strategy in a particular individual. Chronic pain is a common but refractory clinical problem. Its diverse etiologies and broad variations among patients often lead to the requirement of individualizing medicine. Thus, chronic pain represents a classical condition for N-of-1 clinical trials. Studies have indicated that N-of-1 benefits patients with chronic pain, multiple comorbidities, and uncertain variations during therapies; however, this approach it is not yet adopted as the first choice in pain clinics. To dissect the current status of N-of-1 in chronic pain management, as well as the limitations for its implementation, we herein studied all N-of-1 studies related to chronic pain by searching three major databases (PubMed, ClinicalTrial.gov, Cochrane Library) for publications between 1985 and 2020. Of 35 eligibility papers, 19 were selected for analysis. Results confirmed that N-of-1 trials have solved the refractory cases including osteoarthritis, chronic musculoskeletal pain, and neuropathic pain; however, none of the trials dealt with cancer pain. Longer time and more efforts are needed from investigators when carrying out N-of-1 trials, which inevitably result in implementation difficulties. Of note, all recruited trials were conducted in developed countries. As mobile devices have been introduced and protocols improve, renewed interest in the implementation of N-of-1 trials will occur. Collectively, a previously underestimated conflict between "precision medicine" and "poor implementation" has put N-of-1 in a challenging position for chronic pain management.
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Affiliation(s)
- Wanying He
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| | - Zichan Cui
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| | - Yin Chen
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| | - Fang Wang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Er Road, Guangzhou, 510080 China
| | - Fengxian Li
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
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19
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Izem R, McCarter R. Randomized and non-randomized designs for causal inference with longitudinal data in rare disorders. Orphanet J Rare Dis 2021; 16:491. [PMID: 34814939 PMCID: PMC8609847 DOI: 10.1186/s13023-021-02124-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
In the United States, approximately 7000 rare diseases affect 30 million patients, and only 10% of these diseases have existing therapies. Sound study design and causal inference methods are essential to demonstrate the therapeutic efficacy, safety, and effectiveness of new therapies. In the rare diseases setting, several factors challenge the use of typical parallel control designs: the small patient population size, genotypic and phenotypic diversity, and the complexity and incomplete understanding of the disorder’s progression. Repeated measures, when spaced appropriately relative to disease progression and exploited in design and analysis, can increase study power and reduce variability in treatment effect estimation. This paper reviews these longitudinal designs and draws the parallel between some new and existing randomized studies in rare diseases and their less well-known controlled observational study designs. We show that self-controlled randomized crossover and N-of-1 designs have similar considerations as the observational case series and case-crossover designs. Also, randomized sequential designs have similar considerations to longitudinal cohort studies using sequential matching or weighting to control confounding. We discuss design and analysis considerations for valid causal inference and illustrate them with examples of analyses in multiple rare disorders, including urea cycle disorder and cystic fibrosis.
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Affiliation(s)
- Rima Izem
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA.
| | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA
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20
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Kane PB, Bittlinger M, Kimmelman J. Individualized therapy trials: navigating patient care, research goals and ethics. Nat Med 2021; 27:1679-1686. [PMID: 34642487 DOI: 10.1038/s41591-021-01519-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
'Individualized therapy' trials (sometimes called n-of-1 trials) use patients as their own controls to evaluate treatments. Here we divide such trials into three categories: multi-crossover trials aimed at individual patient management, multi-crossover trial series and pre-post trials. These trials all customize interventions for patients; however, the latter two categories also aim to inform medical practice and thus embody tensions between the goals of care and research that are typical of other types of clinical trials. In this Perspective, we discuss four domains where such tensions play out-clinical equipoise, informed consent, reporting and funding, and we provide recommendations for addressing each.
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Affiliation(s)
- Patrick Bodilly Kane
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Merlin Bittlinger
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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21
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Selker HP, Cohen T, D'Agostino RB, Dere WH, Ghaemi SN, Honig PK, Kaitin KI, Kaplan HC, Kravitz RL, Larholt K, McElwee NE, Oye KA, Palm ME, Perfetto E, Ramanathan C, Schmid CH, Seyfert-Margolis V, Trusheim M, Eichler HG. A Useful and Sustainable Role for N-of-1 Trials in the Healthcare Ecosystem. Clin Pharmacol Ther 2021; 112:224-232. [PMID: 34551122 PMCID: PMC9022728 DOI: 10.1002/cpt.2425] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
Clinicians and patients often try a treatment for an initial period to inform longer‐term therapeutic decisions. A more rigorous approach involves N‐of‐1 trials. In these single‐patient crossover trials, typically conducted in patients with chronic conditions, individual patients are given candidate treatments in a double‐blinded, random sequence of alternating periods to determine the most effective treatment for that patient. However, to date, these trials are rarely done outside of research settings and have not been integrated into general care where they could offer substantial benefit. Designating this classical, N‐of‐1 trial design as type 1, there also are new and evolving uses of N‐of‐1 trials that we designate as type 2. In these, rather than focusing on optimizing treatment for chronic diseases when multiple approved choices are available, as is typical of type 1, a type 2 N‐of‐1 trial tests treatments designed specifically for a patient with a rare disease, to facilitate personalized medicine. While the aims differ, both types face the challenge of collecting individual‐patient evidence using standard, trusted, widely accepted methods. To fulfill their potential for producing both clinical and research benefits, and to be available for wide use, N‐of‐1 trials will have to fit into the current healthcare ecosystem. This will require generalizable and accepted processes, platforms, methods, and standards. This also will require sustainable value‐based arrangements among key stakeholders. In this article, we review opportunities, stakeholders, issues, and possible approaches that could support general use of N‐of‐1 trials and deliver benefit to patients and the healthcare enterprise. To assess and expand the benefits of N‐of‐1 trials, we propose multistakeholder meetings, workshops, and the generation of methods, standards, and platforms that would support wider availability and the value of N‐of‐1 trials.
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Affiliation(s)
- Harry P Selker
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Theodora Cohen
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Willard H Dere
- Department of Internal Medicine, Utah Center for Clinical and Translational Science, University of Utah, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - S Nassir Ghaemi
- Psychiatry, Tufts University School of Medicine, Boston, Massachusetts, USA.,Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kenneth I Kaitin
- Tufts Center for the Study of Drug Development, Tufts University, Boston, Massachusetts, USA
| | - Heather C Kaplan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Kay Larholt
- Center for Biomedical Innovation, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Newell E McElwee
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA
| | - Kenneth A Oye
- Department of Political Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | - Marisha E Palm
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Eleanor Perfetto
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.,National Health Council, Washington, District of Columbia, USA
| | | | | | | | - Mark Trusheim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Hans-Georg Eichler
- Regulatory Science and Innovation Task Force, European Medicines Agency, Amsterdam, The Netherlands.,Medical University of Vienna, Vienna, Austria
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22
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Diaz FJ. Using population crossover trials to improve the decision process regarding treatment individualization in N-of-1 trials. Stat Med 2021; 40:4345-4361. [PMID: 34213011 PMCID: PMC10773237 DOI: 10.1002/sim.9030] [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: 11/06/2020] [Revised: 03/26/2021] [Accepted: 04/25/2021] [Indexed: 11/08/2022]
Abstract
Healthcare researchers are showing renewed interest in the utilization of N-of-1 clinical trials for the individualization of pharmacological treatments. Here, we propose a frequentist approach to conducting treatment individualization in N-of-1 trials that we call "partial empirical Bayes." We infer the most beneficial treatment for the patient from combining the information provided by a previously conducted population crossover trial with individual patient data. We propose a method for estimating an optimal number of treatment cycles and investigate the statistical conditions under which N-of-1 trials are more beneficial than traditional clinical approaches. We represent the patient population with a random-coefficients linear model and calculate estimators of posttreatment individual disease severities. We show the estimators' consistency under the most common N-of-1 designs and examine their prediction errors and performance with small numbers of patient's responses. We demonstrate by simulating new patients that our approach is equivalent or superior to both the common clinical practice of recommending the on-average best treatment for all patients and the common individualization method that simply compares average responses to the tested treatments. We conclude that some situations exist in which individualization with N-of-1 trials is highly beneficial while other situations exist in which individualization may be unfruitful.
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Affiliation(s)
- Francisco J Diaz
- Department of Biostatistics & Data Science, The University of Kansas Medical Center, Kansas City, Kansas, USA
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23
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Müller AR, Zinkstok JR, Rommelse NNJ, van de Ven PM, Roes KCB, Wijburg FA, de Rooij-Askes E, Linders C, Boot E, van Eeghen AM. Methylphenidate for attention-deficit/hyperactivity disorder in patients with Smith-Magenis syndrome: protocol for a series of N-of-1 trials. Orphanet J Rare Dis 2021; 16:380. [PMID: 34496899 PMCID: PMC8424817 DOI: 10.1186/s13023-021-02003-z] [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: 03/12/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background Smith–Magenis syndrome (SMS) is a rare genetic neurodevelopmental disorder characterized by intellectual disability and severe behavioural and sleep disturbances. Often, patients with SMS are diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the effectiveness of methylphenidate (MPH), the first-line pharmacological treatment for ADHD, in patients with SMS is unclear. Our objective is to examine the effectiveness of MPH for ADHD symptoms in individuals with SMS, proposing an alternative trial design as traditional randomized controlled trials are complex in these rare and heterogeneous patient populations. Methods and analysis We will initiate an N-of-1 series of double-blind randomized and placebo-controlled multiple crossover trials in six patients aged ≥ 6 years with a genetically confirmed SMS diagnosis and a multidisciplinary established ADHD diagnosis, according to a power analysis based on a summary measures analysis of the treatment effect. Each N-of-1 trial consists of a baseline period, dose titration phase, three cycles each including randomized intervention, placebo and washout periods, and follow-up. The intervention includes twice daily MPH (doses based on age and body weight). The primary outcome measure will be the subscale hyperactivity/inattention of the Strengths and Difficulties Questionnaire (SDQ), rated daily. Secondary outcome measures are the shortened version of the Emotion Dysregulation Inventory (EDI) reactivity index, Goal Attainment Scaling (GAS), and the personal questionnaire (PQ). Statistical analysis will include a mixed model analysis. All subjects will receive an assessment of their individual treatment effect and data will be aggregated to investigate the effectiveness of MPH for ADHD in SMS at a population level. Conclusions This study will provide information on the effectiveness of MPH for ADHD in SMS, incorporating personalized outcome measures. This protocol presents the first properly powered N-of-1 study in a rare genetic neurodevelopmental disorder, providing a much-needed bridge between science and practice to optimize evidence-based and personalized care. Trial registration This study is registered in the Netherlands Trial Register (NTR9125).
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Affiliation(s)
- A R Müller
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J R Zinkstok
- Department of Psychiatry and Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N N J Rommelse
- Karakter, Child and Adolescent Psychiatry, Nijmegen, The Netherlands.,Department of Psychiatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - C Linders
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands
| | - E Boot
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada
| | - A M van Eeghen
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands. .,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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24
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Zarbin MA, Novack G. N-of-1 Clinical Trials: A Scientific Approach to Personalized Medicine for Patients with Rare Retinal Diseases Such as Retinitis Pigmentosa. J Ocul Pharmacol Ther 2021; 37:495-501. [PMID: 34491833 DOI: 10.1089/jop.2021.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
N-of-1 trials are randomized, prospective, controlled, multiple crossover trials in a single patient. Effects of one or more treatments are studied by following individual patients who receive alternative treatments (eg, therapeutic intervention). Such trials may provide a path to assess treatments for rare diseases with rigor equal to or greater than that afforded by parallel group randomized clinical trials provided that the condition is reasonably stable during the trial and has a sign/symptom that responds reversibly to the therapy and that can be measured repeatedly. In this article, the authors propose that N-of-1 trials may improve the feasibility and affordability of clinical trials for patients with rare inherited retinal diseases.
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Affiliation(s)
- Marco A Zarbin
- Institute of Ophthalmology and Visual Science, Rutgers-New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Gary Novack
- PharmaLogic Development, Inc., San Rafael, California, USA.,Department of Ophthalmology & Visual Sciences, School of Medicine, University of California, Davis, Sacramento, California, USA
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25
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Barnett I, Torous J, Reeder HT, Baker J, Onnela JP. Determining sample size and length of follow-up for smartphone-based digital phenotyping studies. J Am Med Inform Assoc 2021; 27:1844-1849. [PMID: 33043370 DOI: 10.1093/jamia/ocaa201] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/06/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Studies that use patient smartphones to collect ecological momentary assessment and sensor data, an approach frequently referred to as digital phenotyping, have increased in popularity in recent years. There is a lack of formal guidelines for the design of new digital phenotyping studies so that they are powered to detect both population-level longitudinal associations as well as individual-level change points in multivariate time series. In particular, determining the appropriate balance of sample size relative to the targeted duration of follow-up is a challenge. MATERIALS AND METHODS We used data from 2 prior smartphone-based digital phenotyping studies to provide reasonable ranges of effect size and parameters. We considered likelihood ratio tests for generalized linear mixed models as well as for change point detection of individual-level multivariate time series. RESULTS We propose a joint procedure for sequentially calculating first an appropriate length of follow-up and then a necessary minimum sample size required to provide adequate power. In addition, we developed an accompanying accessible sample size and power calculator. DISCUSSION The 2-parameter problem of identifying both an appropriate sample size and duration of follow-up for a longitudinal study requires the simultaneous consideration of 2 analysis methods during study design. CONCLUSION The temporally dense longitudinal data collected by digital phenotyping studies may warrant a variety of applicable analysis choices. Our use of generalized linear mixed models as well as change point detection to guide sample size and study duration calculations provide a tool to effectively power new digital phenotyping studies.
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Affiliation(s)
- Ian Barnett
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Torous
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Harrison T Reeder
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Justin Baker
- Department of Psychiatry, McLean Hospital, Boston, Massachusetts, USA
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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26
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Müller AR, Brands MMMG, van de Ven PM, Roes KCB, Cornel MC, van Karnebeek CDM, Wijburg FA, Daams JG, Boot E, van Eeghen AM. Systematic Review of N-of-1 Studies in Rare Genetic Neurodevelopmental Disorders: The Power of 1. Neurology 2021; 96:529-540. [PMID: 33504638 PMCID: PMC8032375 DOI: 10.1212/wnl.0000000000011597] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To improve the use of N-of-1 studies in rare genetic neurodevelopmental disorders, we systematically reviewed the literature and formulated recommendations for future studies. METHODS The systematic review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42020154720). EMBASE and MEDLINE were searched for relevant studies. Information was recorded on types of interventions, outcome measures, validity, strengths, and limitations using standard reporting guidelines and critical appraisal tools. Qualitative and descriptive analyses were performed. RESULTS Twelve studies met the N-of-1 inclusion criteria, including both single trials and series. Interventions were mainly directed to neuropsychiatric manifestations. Main strengths were the use of personalized and clinically relevant outcomes in most studies. Generalizability was compromised due to limited use of validated and generalizable outcome measures. CONCLUSION N-of-1 studies are sporadically reported in rare genetic neurodevelopmental disorders. Properly executed N-of-1 studies may provide a powerful alternative to larger randomized controlled trials in rare disorders and a much needed bridge between practice and science. We provide recommendations for future N-of-1 studies in rare genetic neurodevelopmental disorders, ultimately optimizing evidence-based and personalized care.
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Affiliation(s)
- Annelieke R Müller
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Marion M M G Brands
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Peter M van de Ven
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Kit C B Roes
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Martina C Cornel
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Clara D M van Karnebeek
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Frits A Wijburg
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Joost G Daams
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Erik Boot
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands
| | - Agnies M van Eeghen
- 's Heeren Loo (A.R.M.), Amersfoort, the Netherlands, and Amsterdam UMC (A.R.M.), Pediatric Metabolic Diseases, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (M.M.G.B), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics (P.M.v.d.V.), Amsterdam UMC, Amsterdam, the Netherlands; Department of Health Evidence, Biostatistics (K.C.B.R.), Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands; Department of Clinical Genetics (M.C.C.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Pediatric Metabolic Diseases (C.D.M.v.K.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Department of Pediatrics (C.D.M.v.K.), Radboud University Medical Center, Radboud Centre for Mitochondrial Medicine, Nijmegen, the Netherlands; Pediatric Metabolic Diseases (F.A.W.), Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands; Medical Library (J.G.D.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 's Heeren Loo (E.B.), Amersfoort, the Netherlands, and Department of Psychiatry and Neuropsychology (E.B.), Maastricht University, Maastricht, the Netherlands, University Health Network (E.B.), The Dalglish Family 22q Clinic, Toronto, Ontario, Canada; and 's Heeren Loo (A.M.v.E.), Amersfoort, the Netherlands, Amsterdam UMC (A.M.v.E.), Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands, and Erasmus Medical Center (A.M.v.E.), ENCORE, Rotterdam, the Netherlands.
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Is the N-of-1 method applicable in bodywork research? Lessons learned using a trial as a methodological pilot. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2021; 19:203-210. [PMID: 33583758 DOI: 10.1016/j.joim.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/08/2021] [Indexed: 11/20/2022]
Abstract
N-of-1 trial designs have rarely been used in bodywork research. Using a recent trial as a methodological pilot, critical issues related to the applicability of N-of-1 trials to bodywork are discussed. These include the issues of carry-over effects, bias-controlling approaches and statistical analysis. The discussion highlights the importance of mixed methods and draws some suggestions for a future research program. N-of-1 trials could be used to provide insights about some essential elements of bodywork modalities and their effectiveness.
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Yang M, Sun R, Wang Y, Xu H, Zou B, Yang Y, Cong M, Zheng Y, Yu L, Ma F, Qiu T, Li J. Study Protocol for the Evaluation of Individual Psychological Interventions for Family Caregivers of Advanced Cancer Patients. Front Psychol 2021; 11:587627. [PMID: 33584422 PMCID: PMC7873877 DOI: 10.3389/fpsyg.2020.587627] [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: 07/27/2020] [Accepted: 11/25/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Both anxiety and depression in family caregivers (FCs) of advanced cancer patients are common, and they have a negative influence on both the FCs and the patients. Some studies suggested that a variety of interventions could alleviate the psychological symptoms of FCs. However, there is no consensus on much more effective methods for intervention, and relatively high-quality research is blank in psychological problems of these population in China. The validity of mindfulness-based stress reduction (MBSR) and psychological consultation guided by the needs assessment tool (NST) in the psychological status of caregivers will be compared in this study to select a more suitable intervention for the FCs of advanced cancer patients in China. Methods and Analysis: A randomized N-of-1 trial would be conducted at the Cancer Hospital, Chinese Academy of Medical Sciences. Fifty eligible FCs of advanced cancer patients will be recruited, and all will receive three cycles of psychological intervention treatment, with each cycle including both of MBSR and psychological consultation guided by the NST. MBSR and psychological consultation guided by the NST will be compared with each other in each cycle, and the intervention sequence will be based on the random number table generated after the informed consent has been completed. Each treatment period is 2 weeks, and the interval between different treatment cycles or treatment periods is 1 week. The self-reported scales are measured at the beginning and end of each treatment period, including the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS), Distress Thermometer (DT), Zarit Burden Interview (ZBI), Chinese version of the Medical Outcomes Study 12-item Short Form (C-SF-12), and Family Carer Satisfaction with Palliative Care scale (FAMCARE-2). Dissemination: The protocol of the study was approved by the Institutional Review Board of the Ethical Committee of the Cancer Hospital, Chinese Academic of Medical Science. The results will be published in a peer-reviewed medical journal. The study is registered at Chinese Clinical Trials Registry with the trial registration number chiCTR2000033707. This study employs an innovative methodological approach on the effectiveness of MBSR and psychological consultation guided by the NST for psychological status of FCs of advanced cancer patients. The findings of the study will be helpful to provide high-quality evidence-based medical data for psychological intervention of FCs of advanced cancer patients, and guide clinicians on best quality treatment recommendations.
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Affiliation(s)
- Min Yang
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Sun
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanfeng Wang
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haiyan Xu
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Baohua Zou
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanmin Yang
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minghua Cong
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yadi Zheng
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Yu
- Department of Comprehensive Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Ma
- Department of Internal Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tinglin Qiu
- Division of Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Li
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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29
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Potter T, Vieira R, de Roos B. Perspective: Application of N-of-1 Methods in Personalized Nutrition Research. Adv Nutr 2021; 12:579-589. [PMID: 33460438 PMCID: PMC8166550 DOI: 10.1093/advances/nmaa173] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/20/2020] [Accepted: 12/11/2020] [Indexed: 01/19/2023] Open
Abstract
Personalized and precision nutrition aim to examine and improve health on an individual level, and this requires reconsideration of traditional dietary interventions or behavioral study designs. The limited frequency of measurements in group-level human nutrition trials cannot be used to infer individual responses to interventions, while in behavioral studies, retrospective data collection does not provide an accurate measure of how everyday behaviors affect individual health. This review introduces the concept of N-of-1 study designs, which involve the repeated measurement of a health outcome or behavior on an individual level. Observational designs can be used to monitor a participant's usual health or behavior in a naturalistic setting, with repeated measurements conducted in real time using an Ecological Momentary Assessment. Interventional designs can introduce a dietary or behavioral intervention with predictors and outcomes of interest measured repeatedly either during or after 1 or more intervention and control periods. Due to their flexibility, N-of-1 designs can be applied to both short-term physiological studies and longer-term studies of eating behaviors. As a growing number of disease markers can be measured outside of the clinic, with self-reported data delivered via electronic devices, it is now easier than ever to generate large amounts of data on an individual level. Statistical techniques can be utilized to analyze changes in an individual or to aggregate data from sets of N-of-1 trials, enabling hypotheses to be tested on a small number of heterogeneous individuals. Although their designs necessitate extra methodological and statistical considerations, N-of-1 studies could be used to investigate complex research questions and to study underrepresented groups. This may help to reveal novel associations between participant characteristics and health outcomes, with repeated measures providing power and precision to accurately determine an individual's health status.
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Affiliation(s)
- Tilly Potter
- Rowett Institute, University of Aberdeen, United Kingdom
| | - Rute Vieira
- Institute of Applied Health Sciences, University of Aberdeen, United Kingdom
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30
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DesRuisseaux LA, Williams VJ, McManus AJ, Gupta AS, Carlyle BC, Azami H, Gerber JA, Bolling AM, Cook CL, Betensky RA, Arnold SE. A pilot protocol to assess the feasibility of a virtual multiple crossover, randomized controlled trial design using methylphenidate in mild cognitive impairment. Trials 2020; 21:1016. [PMID: 33308285 PMCID: PMC7729136 DOI: 10.1186/s13063-020-04752-x] [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] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 09/17/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The conventional clinical trial design in Alzheimer's disease (AD) and AD-related disorders (ADRDs) is the parallel-group randomized controlled trial. However, in heterogeneous disorders like AD/ADRDs, this design requires large sample sizes to detect meaningful effects in an "average" patient. They are very costly and, despite many attempts, have not yielded new treatments for many years. An alternative, the multi-crossover, randomized control trial (MCRCT) is a design in which each patient serves as their own control across successive, randomized blocks of active treatment and placebo. This design overcomes many limitations of parallel-group trials, yielding an unbiased assessment of treatment effect at the individual level ("N-of-1") regardless of unique patient characteristics. The goal of the present study is to pilot a MCRCT of a potential symptomatic treatment, methylphenidate, for mild-stage AD/ADRDs, testing feasibility and compliance of participants in this design and efficacy of the drug using both standard and novel outcome measures suited for this design. METHODS Ten participants with mild cognitive impairment or mild-stage dementia due to AD/ADRDs will undergo a 4-week lead-in period followed by three, month-long treatment blocks (2 weeks of treatment with methylphenidate, 2 weeks placebo in random order). This trial will be conducted entirely virtually with an optional in-person screening visit. The primary outcome of interest is feasibility as measured by compliance and retention, with secondary and exploratory outcomes including cognition as measured by neuropsychological assessment at the end of each treatment period and daily brain games played throughout the study, actigraphy, and neuropsychiatric and functional assessments. DISCUSSION This pilot study will gauge the feasibility of conducting a virtual MCRCT for symptomatic treatment in early AD/ADRD. It will also compare home-based daily brain games with standard neuropsychological measures within a clinical trial for AD/ADRD. Particular attention will be paid to compliance, tolerability of drug and participation, learning effects, trends and stability of daily measures across blocks, medication carryover effects, and correlations between standard and brief daily assessments. These data will provide guidance for more efficient trial design and the use of potentially more robust, ecological outcome measures in AD/ADRD research. TRIAL REGISTRATION ClinicalTrials.gov, NCT03811847 . Registered on 21 January 2019.
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Affiliation(s)
- Libby A. DesRuisseaux
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Victoria J. Williams
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Alison J. McManus
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Anoopum S. Gupta
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Becky C. Carlyle
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Hamed Azami
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Jessica A. Gerber
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Anna M. Bolling
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
| | - Carolyn L. Cook
- University of Heidelberg, Heidelberg, Baden Württemberg Germany
| | - Rebecca A. Betensky
- College of Public Global Health, Department of Biostatistics, New York University, New York, NY USA
| | - Steven E. Arnold
- MGH Interdisciplinary Brain Center, Department of Neurology, Massachusetts General Hospital, Boston, MA USA
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31
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Chen YM, Deng JM, Wen Y, Chen B, Hou JT, Peng B, Zhang SJ, Mi H, Jiang QL, Wu XL, Liu FB, Chen XL. Modified Sijunzi decoction in the treatment of ulcerative colitis in the remission phase: study protocol for a series of N-of-1 double-blind, randomised controlled trials. Trials 2020; 21:396. [PMID: 32398112 PMCID: PMC7218572 DOI: 10.1186/s13063-020-04315-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/10/2020] [Indexed: 12/12/2022] Open
Abstract
Background Modified Sijunzi decoction (SJZD) has been used to treat ulcerative colitis (UC) in remission. However, more rigorous clinical trials are necessary to evaluate its effectiveness. Therefore, a series of single-case randomised controlled trials (N-of-1 trials) is proposed to compare the efficacy of modified SJZD with mesalazine for treating UC in remission. Methods This is a single-site, hospital-based, double-blind N-of-1 trial for 10 single subjects. Three cycles of N-of-1 trials are planned. There are two treatment periods in each cycle. Modified SJZD combined with mesalazine placebo or mesalazine combined with modified SJZD placebo will be randomised during each 8-week treatment period. There is no washout period in the study. Subjects will be selected by the researcher strictly in accordance with the inclusion and exclusion criteria. Discussion Paired t tests and mixed-effect models will be used to analyse the visual analogue scale (VAS) for clinical symptoms and the quality of life questionnaire responses. The findings will be interpreted with caution. We anticipate that the results will show that modified SJZD is effective for patients with UC in remission. Trial registration Chinese Clinical Trial Register, ID: ChiCTR1900024086. Registered on 24 June 2019.
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Affiliation(s)
- Yi-Ming Chen
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jie-Min Deng
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yi Wen
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bin Chen
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiang-Tao Hou
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bin Peng
- The First Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shi-Jing Zhang
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hong Mi
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qi-Long Jiang
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xia-Lin Wu
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Feng-Bin Liu
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Xin-Lin Chen
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, China.
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32
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Porcino AJ, Shamseer L, Chan AW, Kravitz RL, Orkin A, Punja S, Ravaud P, Schmid CH, Vohra S. SPIRIT extension and elaboration for n-of-1 trials: SPENT 2019 checklist. BMJ 2020; 368:m122. [PMID: 32107202 DOI: 10.1136/bmj.m122] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Larissa Shamseer
- Centre for Journalology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - An-Wen Chan
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Richard L Kravitz
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Aaron Orkin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine (St Joseph's Health Centre) and Inner City Health Associates, Unity Health, Toronto, ON, Canada
| | - Salima Punja
- Integrative Health Institute, University of Alberta, 1702 College Plaza, 8215-112 Street NW, Edmonton, AB T6G 2C8, Canada
| | - Philippe Ravaud
- Hôpital Hôtel-Dieu, Center for Clinical Epidemiology, Paris, France
- EQUATOR France and Cochrane France, Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité, Paris, France
| | - Christopher H Schmid
- Department of Biostatistics and Center for Evidence Synthesis in Health, Brown University, Providence, RI, USA
| | - Sunita Vohra
- Integrative Health Institute, University of Alberta, 1702 College Plaza, 8215-112 Street NW, Edmonton, AB T6G 2C8, Canada
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
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33
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Tang J, Landes RD. Some t-tests for N-of-1 trials with serial correlation. PLoS One 2020; 15:e0228077. [PMID: 32017772 PMCID: PMC6999905 DOI: 10.1371/journal.pone.0228077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/07/2020] [Indexed: 01/19/2023] Open
Abstract
N-of-1 trials allow inference between two treatments given to a single individual. Most often, clinical investigators analyze an individual's N-of-1 trial data with usual t-tests or simple nonparametric methods. These simple methods do not account for serial correlation in repeated observations coming from the individual. Existing methods accounting for serial correlation require simulation, multiple N-of-1 trials, or both. Here, we develop t-tests that account for serial correlation in a single individual. The development includes effect size and precision calculations, both of which are useful for study planning. We then use Monte Carlo simulation to evaluate statistical properties of these serial t-tests, namely, Type I and II errors, and confidence interval widths, and compare these statistical properties to those of analogous usual t-test. The serial t-tests clearly outperform the usual t-tests commonly used in reporting N-of-1 results. Examples from N-of-1 clinical trials in fibromyalgia patients and from a behavioral health setting exhibit how accounting for serial correlation can change inferences. These t-tests are easily implemented and more appropriate than simple methods commonly used; however, caution is needed when analyzing only a few observations.
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Affiliation(s)
- Jillian Tang
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Reid D. Landes
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
- * E-mail:
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Sierra-Arango F, Castaño DM, Forero JD, Pérez-Riveros ED, Ardila Duarte G, Botero ML, Cárdenas A, De la Hoz-Valle J. A Randomized Placebo-Controlled N-of-1 Trial: The Effect of Proton Pump Inhibitor in the Management of Gastroesophageal Reflux Disease. Can J Gastroenterol Hepatol 2019; 2019:3926051. [PMID: 31929980 PMCID: PMC6935808 DOI: 10.1155/2019/3926051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/30/2019] [Indexed: 01/10/2023] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is the most frequent chronic gastrointestinal disorder. It is defined as a condition developed when the reflux of gastric contents causes troublesome symptoms (heartburn and regurgitation). This requires adequate treatment since it can lead to long-term complications including esophagus adenocarcinoma. Proton pump inhibitors (PPI) are generally used to treat GERD due to their high-security profile and efficiency on most patients. However, recurrent reflux despite initial treatment is frequent. N-of-1 trial is a study that allows the identification of the best treatment for each patient. The objective of this study is to compare the efficacy of standard dose with double dosage of esomeprazole, to improve the GERD symptoms in a single patient. Methods A single-patient trial, placebo-controlled, randomized, double-blind, was carried out from September 25th, 2012, to April 26th, 2013. It included one outpatient at the gastroenterology service in a fourth-level hospital, diagnosed with nonerosive reflux disease (NERD). Yet, his symptoms were heartburn and reflux, and his endoscopic results were normal esophageal mucosa, without hiatal hernia, though pathological pH values. A no-obese male without any tobacco or alcohol usage received esomeprazole 40 mg/day and 40 mg/bid for 24 weeks. A standardized gastroesophageal reflux disease questionnaire (GerdQ) was used weekly to evaluate symptom frequency and severity. The consumption of 90% of the capsules was considered as an adequate treatment adherence. D'agostino-Pearson and Wilcoxon test were used to determine normal or nonnormal distribution and compare both treatments, respectively, both with a significant statistical difference of p < 0.05. Results The patient completed the study with 96% of adherence. The double dosage of esomeprazole did not improve the control of symptoms compared with the standard dosage. Mean symptomatic score was 9.5±0.5 and 10.2±0.6 for each treatment, respectively (p > 0.05). Conclusion There was no significant improvement in the patient GERD symptoms increasing the dose of oral esomeprazole during the 6 months of study. N-of-1 trials in chronic pathologies including GERD are recommended due to their potential value as systematic methods that evaluate therapies without strong scientific evidence.
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Affiliation(s)
- Fernando Sierra-Arango
- Gastroenterology and Hepatology Department, Fundación Santa Fe de Bogotá, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - D. M. Castaño
- Gastroenterology and Hepatology Department, Fundación Santa Fe de Bogotá, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Jennifer D. Forero
- Gastroenterology and Hepatology Department, Fundación Santa Fe de Bogotá, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | | | - Maria L. Botero
- Pathology Department, Hospital Universitari Vall de Hebron, Barcelona, Spain
| | - Andres Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives Metaboliques, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jose De la Hoz-Valle
- Head of Subdirección de Estudios Clínicos y Epidemiología Clínica (SECEC), Fundación Santa Fe de Bogotá, Bogotá, Colombia
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Blackston JW, Chapple AG, McGree JM, McDonald S, Nikles J. Comparison of Aggregated N-of-1 Trials with Parallel and Crossover Randomized Controlled Trials Using Simulation Studies. Healthcare (Basel) 2019; 7:healthcare7040137. [PMID: 31698799 PMCID: PMC6955665 DOI: 10.3390/healthcare7040137] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 10/23/2019] [Accepted: 11/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background: N-of-1 trials offer an innovative approach to delivering personalized clinical care together with population-level research. While increasingly used, these methods have raised some statistical concerns in the healthcare community. Methods: We discuss concerns of selection bias, carryover effects from treatment, and trial data analysis conceptually, then rigorously evaluate concerns of effect sizes, power and sample size through simulation study. Four variance structures for patient heterogeneity and model error are considered in a series of 5000 simulated trials with 3 cycles, which compare aggregated N-of-1 trials to parallel randomized controlled trials (RCTs) and crossover trials. Results: Aggregated N-of-1 trials outperformed both traditional parallel RCT and crossover designs when these trial designs were simulated in terms of power and required sample size to obtain a given power. N-of-1 designs resulted in a higher type-I error probability than parallel RCT and cross over designs when moderate-to-strong carryover effects were not considered or in the presence of modeled selection bias. However, N-of-1 designs allowed better estimation of patient-level random effects. These results reinforce the need to account for these factors when planning N-of-1 trials. Conclusion: N-of-1 trial designs offer a rigorous method for advancing personalized medicine and healthcare with the potential to minimize costs and resources. Interventions can be tested with adequate power with far fewer patients than traditional RCT and crossover designs. Operating characteristics compare favorably to both traditional RCT and crossover designs.
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Affiliation(s)
- J. Walker Blackston
- Department of Epidemiology, Tulane University School of Public Health & Tropical Medicine, New Orleans, LA 70112, USA
- Correspondence:
| | - Andrew G. Chapple
- Biostatistics Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA;
| | - James M. McGree
- School of Mathematical Sciences, Queensland University of Technology, Brisbane 2434, Australia;
| | - Suzanne McDonald
- UQCCR, The University of Queensland, Brisbane 4006, Australia; (S.M.); (J.N.)
| | - Jane Nikles
- UQCCR, The University of Queensland, Brisbane 4006, Australia; (S.M.); (J.N.)
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Nag N, Pandey V, Putzel PJ, Bhimaraju H, Krishnan S, Jain R. Cross-Modal Health State Estimation. PROCEEDINGS OF THE ... ACM INTERNATIONAL CONFERENCE ON MULTIMEDIA, WITH CO-LOCATED SYMPOSIUM & WORKSHOPS. ACM INTERNATIONAL CONFERENCE ON MULTIMEDIA 2018; 2018:1993-2002. [PMID: 31131378 PMCID: PMC6530992 DOI: 10.1145/3240508.3241913] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Individuals create and consume more diverse data about themselves today than any time in history. Sources of this data include wearable devices, images, social media, geo-spatial information and more. A tremendous opportunity rests within cross-modal data analysis that leverages existing domain knowledge methods to understand and guide human health. Especially in chronic diseases, current medical practice uses a combination of sparse hospital based biological metrics (blood tests, expensive imaging, etc.) to understand the evolving health status of an individual. Future health systems must integrate data created at the individual level to better understand health status perpetually, especially in a cybernetic framework. In this work we fuse multiple user created and open source data streams along with established biomedical domain knowledge to give two types of quantitative state estimates of cardiovascular health. First, we use wearable devices to calculate cardiorespiratory fitness (CRF), a known quantitative leading predictor of heart disease which is not routinely collected in clinical settings. Second, we estimate inherent genetic traits, living environmental risks, circadian rhythm, and biological metrics from a diverse dataset. Our experimental results on 24 subjects demonstrate how multi-modal data can provide personalized health insight. Understanding the dynamic nature of health status will pave the way for better health based recommendation engines, better clinical decision making and positive lifestyle changes.
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Arnold SE, Betensky RA. Multicrossover Randomized Controlled Trial Designs in Alzheimer Disease. Ann Neurol 2018; 84:168-175. [PMID: 30014506 DOI: 10.1002/ana.25280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/28/2018] [Accepted: 06/24/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Steven E Arnold
- Interdisciplinary Brain Center for Clinical and Translational Research and Department of Neurology, Massachusetts General Hospital, Charlestown, MA
| | - Rebecca A Betensky
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
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Galvin JE. Advancing personalized treatment of Alzheimer's disease: a call for the N-of-1 trial design. FUTURE NEUROLOGY 2018. [DOI: 10.2217/fnl-2018-0004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There has not been a new treatment for Alzheimer's disease (AD) for over a decade, with a large number of Phase II/III randomized clinical trials failing. Randomized clinical trials examine group effects that may be difficult to extrapolate to the individual patient given the multifactorial pathogenic processes associated with AD, and are increasingly long in duration, expensive to run, requiring large sample sizes that are difficult to recruit. An alternative approach is to consider N-of-1 trial designs. The N-of-1 trial is ideal to evaluate effectiveness of interventions for chronic conditions combining the rigor of a randomized trial with the tailoring of therapy to an individual. This review examines the N-of-1 design, its benefits and limitations, and how it could be implemented to investigate new therapies for AD.
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Affiliation(s)
- James E Galvin
- Comprehensive Center for Brain Health, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road ME-104, Rm 102 Boca Raton, FL 33431, USA
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Hecksteden A, Pitsch W, Rosenberger F, Meyer T. Repeated testing for the assessment of individual response to exercise training. J Appl Physiol (1985) 2018; 124:1567-1579. [DOI: 10.1152/japplphysiol.00896.2017] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Observed response to regular exercise training differs widely between individuals even in tightly controlled research settings. However, the respective contributions of random error and true interindividual differences as well as the relative frequency of nonresponders are disputed. Specific challenges of analyses on the individual level as well as a striking heterogeneity in definitions may partly explain these inconsistent results. Repeated testing during the training phase specifically addresses the requirements of analyses on the individual level. Here we report a first implementation of this innovative design amendment in a head-to-head comparison of existing analytical approaches. To allow for comparative implementation of approaches we conducted a controlled endurance training trial (1 yr walking/jogging, 3 days/wk for 45 min with 60% heart rate reserve) in healthy, untrained subjects ( n = 36, age = 46 ± 8 yr; body mass index 24.7 ± 2.7 kg/m2; V̇o2max 36.6 ± 5.4). In the training group additional V̇o2max tests were conducted after 3, 6, and 9 mo. Duration of the control condition was 6 mo due to ethical constraints. General efficacy of the training intervention could be verified by a significant increase in V̇o2max in the training group ( P < 0.001 vs. control). Individual training response of relevant magnitude (>0.2 × baseline variability in V̇o2max) could be demonstrated by several approaches. Regarding the classification of individuals, only 11 of 20 subjects were consistently classified, demonstrating remarkable disagreement between approaches. These results are in support of relevant interindividual variability in training efficacy and stress the limitations of a responder classification. Moreover, this proof-of-concept underlines the need for tailored methodological approaches for well-defined problems. NEW & NOTEWORTHY This work reports a first implementation of a repeated testing training trial for the investigation of individual response. This design amendment was recently proposed to address specifically the statistical requirements of analyses on the individual level. Moreover, a comprehensive comparison of previously published methods exemplifies the striking heterogeneity of existing approaches.
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Affiliation(s)
- Anne Hecksteden
- Institute of Sports and Preventive Medicine, Saarland University, Saarbruecken, Germany
| | - Werner Pitsch
- Institute for Sport Sciences, Department of Sociology and Economics of Sports, Saarland University, Saarbruecken, Germany
| | - Friederike Rosenberger
- Heidelberg University Hospital, National Center for Tumor Diseases (NCT), Heidelberg, Germany
- German University of Applied Sciences for Prevention and Health Management (DHfPG), Saarbrücken, Germany
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Saarbruecken, Germany
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Hilgers RD, Bogdan M, Burman CF, Dette H, Karlsson M, König F, Male C, Mentré F, Molenberghs G, Senn S. Lessons learned from IDeAl - 33 recommendations from the IDeAl-net about design and analysis of small population clinical trials. Orphanet J Rare Dis 2018; 13:77. [PMID: 29751809 PMCID: PMC5948846 DOI: 10.1186/s13023-018-0820-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/01/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND IDeAl (Integrated designs and analysis of small population clinical trials) is an EU funded project developing new statistical design and analysis methodologies for clinical trials in small population groups. Here we provide an overview of IDeAl findings and give recommendations to applied researchers. METHOD The description of the findings is broken down by the nine scientific IDeAl work packages and summarizes results from the project's more than 60 publications to date in peer reviewed journals. In addition, we applied text mining to evaluate the publications and the IDeAl work packages' output in relation to the design and analysis terms derived from in the IRDiRC task force report on small population clinical trials. RESULTS The results are summarized, describing the developments from an applied viewpoint. The main result presented here are 33 practical recommendations drawn from the work, giving researchers a comprehensive guidance to the improved methodology. In particular, the findings will help design and analyse efficient clinical trials in rare diseases with limited number of patients available. We developed a network representation relating the hot topics developed by the IRDiRC task force on small population clinical trials to IDeAl's work as well as relating important methodologies by IDeAl's definition necessary to consider in design and analysis of small-population clinical trials. These network representation establish a new perspective on design and analysis of small-population clinical trials. CONCLUSION IDeAl has provided a huge number of options to refine the statistical methodology for small-population clinical trials from various perspectives. A total of 33 recommendations developed and related to the work packages help the researcher to design small population clinical trial. The route to improvements is displayed in IDeAl-network representing important statistical methodological skills necessary to design and analysis of small-population clinical trials. The methods are ready for use.
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Affiliation(s)
- Ralf-Dieter Hilgers
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany.
| | - Malgorzata Bogdan
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Carl-Fredrik Burman
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Holger Dette
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Mats Karlsson
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Franz König
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Christoph Male
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - France Mentré
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Geert Molenberghs
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
| | - Stephen Senn
- Department of Medical Statistics, RWTH Aachen University, Pauwelsstr. 19, D-52074, Aachen, Germany
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