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Bobe JR, Buros J, Golden E, Johnson M, Jones M, Percha B, Viglizzo R, Zimmerman N. Factors Associated With Trial Completion and Adherence in App-Based N-of-1 Trials: Protocol for a Randomized Trial Evaluating Study Duration, Notification Level, and Meaningful Engagement in the Brain Boost Study. JMIR Res Protoc 2020; 9:e16362. [PMID: 31913135 PMCID: PMC6996754 DOI: 10.2196/16362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 11/13/2022] Open
Abstract
Background
N-of-1 trials promise to help individuals make more informed decisions about treatment selection through structured experiments that compare treatment effectiveness by alternating treatments and measuring their impacts in a single individual. We created a digital platform that automates the design, administration, and analysis of N-of-1 trials. Our first N-of-1 trial, the app-based Brain Boost Study, invited individuals to compare the impacts of two commonly consumed substances (caffeine and L-theanine) on their cognitive performance.
Objective
The purpose of this study is to evaluate critical factors that may impact the completion of N-of-1 trials to inform the design of future app-based N-of-1 trials. We will measure study completion rates for participants that begin the Brain Boost Study and assess their associations with study duration (5, 15, or 27 days) and notification level (light or moderate).
Methods
Participants will be randomized into three study durations and two notification levels. To sufficiently power the study, a minimum of 640 individuals must begin the study, and 97 individuals must complete the study. We will use a multiple logistic regression model to discern whether the study length and notification level are associated with the rate of study completion. For each group, we will also compare participant adherence and the proportion of trials that yield statistically meaningful results.
Results
We completed the beta testing of the N1 app on a convenience sample of users. The Brain Boost Study on the N1 app opened enrollment to the public in October 2019. More than 30 participants enrolled in the first month.
Conclusions
To our knowledge, this will be the first study to rigorously evaluate critical factors associated with study completion in the context of app-based N-of-1 trials.
Trial Registration
ClinicalTrials.gov NCT04056650; https://clinicaltrials.gov/ct2/show/NCT04056650
International Registered Report Identifier (IRRID)
PRR1-10.2196/16362
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Affiliation(s)
- Jason R Bobe
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jacqueline Buros
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eddye Golden
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Matthew Johnson
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Michael Jones
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Bethany Percha
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ryan Viglizzo
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Noah Zimmerman
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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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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Germini F, Coerezza A, Andreinetti L, Nobili A, Rossi PD, Mari D, Guyatt G, Marcucci M. N-of-1 Randomized Trials of Ultra-Micronized Palmitoylethanolamide in Older Patients with Chronic Pain. Drugs Aging 2018; 34:941-952. [PMID: 29210011 DOI: 10.1007/s40266-017-0506-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ultra-micronized palmitoylethanolamide (um-PEA) represents an attractive option for chronic pain control in complex older patients at higher risk of adverse effects with traditional analgesics. OBJECTIVE The aim of this study was to determine the effectiveness of um-PEA versus placebo on chronic pain intensity and function in individual geriatric patients. DESIGN We performed randomized, blinded N-of-1 trials with two 3-week um-PEA versus placebo comparisons, separated by 2-week washout periods. PARTICIPANTS The study included outpatients aged ≥ 65 years with chronic, non-cancer, non-ischemic pain in the back, joints, or limbs. INTERVENTION Patients were randomized to Um-PEA 600 mg or placebo twice daily. MEASUREMENTS Pain intensity was measured using an 11-point visual numeric scale. Functional impairment was measured using a Back Pain Functional Scale. Impact of each N-of-1 trial was measured on the clinician's intention to treat and confidence. RESULTS Ten of 11 eligible patients consented over 7 months [all female, mean age 83.2 years (SD 4.6)]. Three patients interrupted the trial: one had diarrhea (under placebo), one for low adherence, and one for intercurrent pneumonia. A small statistically significant effect in favor of um-PEA was seen at the mixed method analyses in two patients (effect size equal to 8% of the baseline pain). A statistically significant impact on function was found in one patient. After the trial, um-PEA was prescribed to four patients; in two patients the clinician changed their pre-trial intention to treat; the clinician confidence in the treatment plan either increased (5) or remained the same (2). CONCLUSIONS Our experience confirmed that N-of-1 trials may help make personalized evidence-based decisions in complex older patients, with special feasibility considerations. CLINICALTRIALS.GOV: NCT02699281.
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Affiliation(s)
- Federico Germini
- Geriatric Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
- Department of Health Research Methods, Evidence, and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada
| | - Anna Coerezza
- Geriatric Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Luca Andreinetti
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Nobili
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Paolo Dionigi Rossi
- Geriatric Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Mari
- Geriatric Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada
| | - Maura Marcucci
- Geriatric Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Health Research Methods, Evidence, and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, 1280 Main St. W, Hamilton, ON, L8S 4K1, Canada.
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
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Porcino AJ, Punja S, Chan AW, Kravitz R, Orkin A, Ravaud P, Schmid CH, Vohra S. Protocol for a systematic review of N-of-1 trial protocol guidelines and protocol reporting guidelines. Syst Rev 2017; 6:132. [PMID: 28679407 PMCID: PMC5498872 DOI: 10.1186/s13643-017-0525-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/16/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND N-of-1 trials are multiple cross-over trials done in individual participants, generating individual treatment effect information. While reporting guidelines for the CONSORT Extension for N-of-1 trials (CENT) and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) already exist, there is no standardized recommendation for the reporting of N-of-1 trial protocols. OBJECTIVE The objective of this study is to evaluate current literature on N-of-1 design and reporting to identify key elements of rigorous N-of-1 protocol design. METHODS We will conduct a systematic search for all N-of-1 trial guidelines and protocol-reporting guidelines published in peer-reviewed literature. We will search Medline, Embase, PsycINFO, CINAHL, the Cochrane Methodology Register, CENTRAL, and the NHS Economic Evaluation Database. Eligible articles will contain explicit guidance on N-of-1 protocol construction or reporting. Two reviewers will independently screen all titles and abstracts and then undertake full-text reviews of potential articles to determine eligibility. One reviewer will perform data extraction of selected articles, checked by the second reviewer. Data analysis will ascertain common features of N-of-1 trial protocols and compare them to the SPIRIT and CENT items. DISCUSSION This systematic review assesses recommendations on the design and reporting of N-of-1 trial protocols. These findings will inform an international Delphi development process for an N-of-1 trial protocol reporting guideline. The development of this guideline is critical for improving the quality of N-of-1 protocols, leading to improvements in the quality of published N-of-1 trial research.
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Affiliation(s)
- Antony J Porcino
- CARE Program, Department of Pediatrics, Faculty of Medicine and Dentistry, and Integrative Health Institute, University of Alberta, Suite #1702, College Plaza 8215 112 St. NW, Edmonton, AB, T6G 2C8, Canada
| | - Salima Punja
- CARE Program, Department of Pediatrics, Faculty of Medicine and Dentistry, and Integrative Health Institute, University of Alberta, Suite #1702, College Plaza 8215 112 St. NW, Edmonton, AB, T6G 2C8, Canada
| | - An-Wen Chan
- Women's College Research Institute, Women's College Hospital, Department of Medicine, University of Toronto, 76 Grenville St, Toronto, ON, M5S 1B1, Canada
| | - Richard Kravitz
- UC Davis Department of Internal Medicine, 4150 V St., Sacramento, CA, 95817, USA
| | - Aaron Orkin
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 1P8, Canada
| | - Philippe Ravaud
- EQUATOR France, Centre d'épidémiologie clinique, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, 75004, France
| | - Christopher H Schmid
- Center for Evidence Based Medicine, School of Public Health, Brown University, 121 South Main Street, 8th Floor, Providence, RI, 02903, USA
| | - Sunita Vohra
- CARE Program, Department of Pediatrics, Faculty of Medicine and Dentistry, and Integrative Health Institute, University of Alberta, Suite #1702, College Plaza 8215 112 St. NW, Edmonton, AB, T6G 2C8, Canada.
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Mannucci PM, Nobili A. Multimorbidity and polypharmacy in the elderly: lessons from REPOSI. Intern Emerg Med 2014; 9:723-34. [PMID: 25164413 DOI: 10.1007/s11739-014-1124-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 08/20/2014] [Indexed: 12/21/2022]
Abstract
The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists. Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Scientific Direction, IRCCS Foundation Maggiore Hospital Policlinico, Via Francesco Sforza 28, 20122, Milan, Italy,
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Sackett DL. Clinician-trialist rounds: 18. Should young (and old!) clinician-trialists perform single-arm Phase II futility trials? Clin Trials 2013; 10:987-9. [DOI: 10.1177/1740774513503523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David L Sackett
- Trout Research & Education Centre at Irish Lake, Markdale, ON, Canada
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Duan N, Kravitz RL, Schmid CH. Single-patient (n-of-1) trials: a pragmatic clinical decision methodology for patient-centered comparative effectiveness research. J Clin Epidemiol 2013; 66:S21-8. [PMID: 23849149 DOI: 10.1016/j.jclinepi.2013.04.006] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 03/14/2013] [Accepted: 04/22/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To raise awareness among clinicians and epidemiologists that single-patient (n-of-1) trials are potentially useful for informing personalized treatment decisions for patients with chronic conditions. STUDY DESIGN AND SETTING We reviewed the clinical and statistical literature on methods and applications of single-patient trials and then critically evaluated the needs for further methodological developments. RESULTS Existing literature reports application of 2,154 single-patient trials in 108 studies for diverse clinical conditions; various recent commentaries advocate for wider application of such trials in clinical decision making. Preliminary evidence from several recent pilot acceptability studies suggests that single-patient trials have the potential for widespread acceptance by patients and clinicians as an effective modality for increasing the therapeutic precision. Bayesian and adaptive statistical methods hold promise for increasing the informational yield of single-patient trials while reducing participant burden, but are not widely used. Personalized applications of single-patient trials can be enhanced through further development and application of methodologies on adaptive trial design, stopping rules, network meta-analysis, washout methods, and methods for communicating trial findings to patients and clinicians. CONCLUSIONS Single-patient trials may be poised to emerge as an important part of the methodological armamentarium for comparative effectiveness research and patient-centered outcomes research. By permitting direct estimation of individual treatment effects, they can facilitate finely graded individualized care, enhance therapeutic precision, improve patient outcomes, and reduce costs.
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Affiliation(s)
- Naihua Duan
- Division of Biostatistics, Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 48, New York, NY 10032, USA.
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