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Dupuis F, Perreault K, Hébert LJ, Perron M, Fredette A, Desmeules F, Roy JS. Group Physical Therapy Programs for Military Members With Musculoskeletal Disorders: A Pragmatic Randomized Controlled Trial. J Orthop Sports Phys Ther 2024; 54:1-10. [PMID: 38530230 DOI: 10.2519/jospt.2024.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
OBJECTIVE: To compare the effects of personalized, supervised group-based programs (ie, group physical therapy programs) and usual one-on-one physical therapy care (ie, usual physical therapy care) on disability for military personnel suffering from low back pain, rotator cuff-related shoulder pain, patellofemoral pain syndrome, or lateral ankle sprain. Secondary outcomes were pain severity, pain-related fear, health-related quality of life, and patients' satisfaction with their condition and care. DESIGN: Non-inferiority pragmatic randomized clinical trial. METHODS: One hundred twenty military personnel from the Canadian Armed Forces, experiencing 1 of 4 targeted musculoskeletal disorders, were consecutively recruited and randomly assigned to group physical therapy programs or usual physical therapy care. Disability, pain severity, pain-related fear, and health-related quality-of-life outcomes were measured at 6, 12, and 26 weeks after baseline. Satisfaction with treatment was evaluated at the end of the intervention. Intention-to-treat analyses using linear mixed models with random effects were used to compare the effects of interventions. Chi-square tests were used to compare satisfaction. RESULTS: There were no significant Time × Group interactions for any of the primary and secondary outcomes (Time × Group: P>.67). Satisfaction with treatment also did not differ between groups (P>.05). Statistically significant and clinically important improvements were observed in both groups for all outcomes after 12 weeks (Time effect: P<.01), except for health-related quality of life (P = .13). CONCLUSION: Group physical therapy programs were not inferior to usual physical therapy care for managing pain, functional capacity, and patients' satisfaction with care of military personnel presenting with various musculoskeletal disorders. Both interventions led to clinical and statistical improvement in pain and function in the mid and long term. Group physical therapy could be an effective strategy to enhance access to care. J Orthop Sports Phys Ther 2024;54(6):1-10. Epub 26 Mar 2024. doi:10.2519/jospt.2024.12342.
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Coart E, Bamps P, Quinaux E, Sturbois G, Saad ED, Burzykowski T, Buyse M. Minimization in randomized clinical trials. Stat Med 2023; 42:5285-5311. [PMID: 37867447 DOI: 10.1002/sim.9916] [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: 10/13/2022] [Revised: 08/23/2023] [Accepted: 09/13/2023] [Indexed: 10/24/2023]
Abstract
In randomized trials, comparability of the treatment groups is ensured through allocation of treatments using a mechanism that involves some random element, thus controlling for confounding of the treatment effect. Completely random allocation ensures comparability between the treatment groups for all known and unknown prognostic factors. For a specific trial, however, imbalances in prognostic factors among the treatment groups may occur. Although accidental bias can be avoided in the presence of such imbalances by stratifying the analysis, most trialists, regulatory agencies, and other stakeholders prefer a balanced distribution of prognostic factors across the treatment groups. Some procedures attempt to achieve balance in baseline covariates, by stratifying the allocation for these covariates, or by dynamically adapting the allocation using covariate information during the trial (covariate-adaptive procedures). In this Tutorial, the performance of minimization, a popular covariate-adaptive procedure, is compared with two other commonly used procedures, completely random allocation and stratified blocked designs. Using individual patient data of 2 clinical trials (in advanced ovarian cancer and age-related macular degeneration), the procedures are compared in terms of operating characteristics (using asymptotic and randomization tests), predictability of treatment allocation, and achieved balance. Fifty actual trials of various sizes that applied minimization for treatment allocation are used to investigate the achieved balance. Implementation issues of minimization are described. Minimization procedures are useful in all trials but especially when (1) many major prognostic factors are known, (2) many centers of different sizes accrue patients, or (3) the trial sample size is moderate.
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Affiliation(s)
| | | | | | | | | | - Tomasz Burzykowski
- IDDI, Louvain-la-Neuve, Belgium
- Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Marc Buyse
- IDDI, Louvain-la-Neuve, Belgium
- Data Science Institute, Hasselt University, Hasselt, Belgium
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Keynejad RC, Bitew T, Sorsdahl K, Myers B, Honikman S, Medhin G, Deyessa N, Mulushoa A, Fekadu E, Howard LM, Hanlon C. Problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence: A randomised, controlled feasibility trial in rural Ethiopia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002054. [PMID: 37889918 PMCID: PMC10610520 DOI: 10.1371/journal.pgph.0002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
Evidence for the feasibility of brief psychological interventions for pregnant women experiencing intimate partner violence (IPV) in rural, low-income country settings is scarce. In rural Ethiopia, the prevalence of antenatal depressive symptoms and lifetime IPV are 29% and 61%, respectively. We aimed to assess the feasibility and related implementation outcomes of brief problem-solving therapy (PST) adapted for pregnant women experiencing IPV (PST-IPV) in rural Ethiopia, and of a randomised, controlled feasibility study design. We recruited 52 pregnant women experiencing depressive symptoms and past-year IPV from two antenatal care (ANC) services. Consenting women were randomised to PST-IPV (n = 25), 'standard' PST (not adapted for women experiencing IPV; n = 12) or enhanced usual care (information about sources of support; n = 15). Masked data collectors conducted outcome assessments nine weeks post-enrolment. Addis Ababa University (#032/19/CDT) and King's College London (#HR-18/19-9230) approved the study. Fidelity to randomisation was impeded by strong cultural norms about what constituted IPV. However, recruitment was feasible (recruitment rate: 1.5 per day; 37% of women screened were eligible). The intervention and trial were acceptable to women (4% declined initial screening, none declined to participate, and 76% attended all four sessions of either active intervention). PST-IPV was acceptable to ANC providers: none dropped out. Sessions lasting up to a mean 52 minutes raised questions about the appropriateness of the model to this context. Competence assessments recommended supplementary communication skills training. Fidelity assessments indicated high adherence, quality, and responsiveness but assessing risks and social networks, and discussing confidentiality needed improvement. Adjustments to optimise a future, fully powered, randomised controlled trial include staggering recruitment in line with therapist availability, more training on the types of IPV and how to discuss them, automating randomisation, a supervision cascade model, and conducting post-intervention outcome assessments immediately and three months postpartum. Registration: Pan African Clinical Trials Registry #PACTR202002513482084 (13/12/2019): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9601.
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Affiliation(s)
- Roxanne C. Keynejad
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, Section of Women’s Mental Health, King’s College London, Denmark Hill, London, United Kingdom
| | - Tesera Bitew
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Psychology, College of Education and Behavioural Sciences, Injibara University, Injibara, Ethiopia
| | - Katherine Sorsdahl
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Bronwyn Myers
- Department of Psychiatry and Mental Health, Division of Addiction Psychiatry, University of Cape Town, Cape Town, South Africa
- Curtin enAble Institute, Curtin University, Bentley, Western Australia, Australia
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Simone Honikman
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry and Mental Health, Perinatal Mental Health Project, University of Cape Town, Cape Town, South Africa
| | - Girmay Medhin
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Negussie Deyessa
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Adiyam Mulushoa
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eshcolewyine Fekadu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Louise M. Howard
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, Section of Women’s Mental Health, King’s College London, Denmark Hill, London, United Kingdom
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, Denmark Hill, London, United Kingdom
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Messmer A, Pietsch U, Siegemund M, Buehler P, Waskowski J, Müller M, Uehlinger DE, Hollinger A, Filipovic M, Berger D, Schefold JC, Pfortmueller CA. Protocolised early de-resuscitation in septic shock (REDUCE): protocol for a randomised controlled multicentre feasibility trial. BMJ Open 2023; 13:e074847. [PMID: 37734896 PMCID: PMC11148668 DOI: 10.1136/bmjopen-2023-074847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Fluid overload is associated with excess mortality in septic shock. Current approaches to reduce fluid overload include restrictive administration of fluid or active removal of accumulated fluid. However, evidence on active fluid removal is scarce. The aim of this study is to assess the efficacy and feasibility of an early de-resuscitation protocol in patients with septic shock. METHODS All patients admitted to the intensive care unit (ICU) with a septic shock are screened, and eligible patients will be randomised in a 1:1 ratio to intervention or standard of care. INTERVENTION Fluid management will be performed according to the REDUCE protocol, where resuscitation fluid will be restricted to patients showing signs of poor tissue perfusion. After the lactate has peaked, the patient is deemed stable and assessed for active de-resuscitation (signs of fluid overload). The primary objective of this study is the proportion of patients with a negative cumulative fluid balance at day 3 after ICU. Secondary objectives are cumulative fluid balances throughout the ICU stay, number of patients with fluid overload, feasibility and safety outcomes and patient-centred outcomes. The primary outcome will be assessed by a logistic regression model adjusting for the stratification variables (trial site and chronic renal failure) in the intention-to-treat population. ETHICS AND DISSEMINATION The study was approved by the respective ethical committees (No 2020-02197). The results of the REDUCE trial will be published in an international peer-reviewed medical journal regardless of the results. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT04931485.
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Affiliation(s)
- Anna Messmer
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Urs Pietsch
- Department of operative Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Philipp Buehler
- Department of Intensive Care Medicine, Cantonal Hospital Winterthu, Winterthur, Switzerland
| | - Jan Waskowski
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Dominik E Uehlinger
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Miodrag Filipovic
- Department of operative Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - David Berger
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Joerg C Schefold
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Carmen A Pfortmueller
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
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Yelland LN, Louise J, Kahan BC, Morris TP, Lee KJ, Sullivan TR. Handling misclassified stratification variables in the analysis of randomised trials with continuous outcomes. Stat Med 2023; 42:3529-3546. [PMID: 37365776 PMCID: PMC7614797 DOI: 10.1002/sim.9818] [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: 09/06/2022] [Revised: 04/11/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023]
Abstract
Many trials use stratified randomisation, where participants are randomised within strata defined by one or more baseline covariates. While it is important to adjust for stratification variables in the analysis, the appropriate method of adjustment is unclear when stratification variables are affected by misclassification and hence some participants are randomised in the incorrect stratum. We conducted a simulation study to compare methods of adjusting for stratification variables affected by misclassification in the analysis of continuous outcomes when all or only some stratification errors are discovered, and when the treatment effect or treatment-by-covariate interaction effect is of interest. The data were analysed using linear regression with no adjustment, adjustment for the strata used to perform the randomisation (randomisation strata), adjustment for the strata if all errors are corrected (true strata), and adjustment for the strata after some errors are discovered and corrected (updated strata). The unadjusted model performed poorly in all settings. Adjusting for the true strata was optimal, while the relative performance of adjusting for the randomisation strata or the updated strata varied depending on the setting. As the true strata are unlikely to be known with certainty in practice, we recommend using the updated strata for adjustment and performing subgroup analyses, provided the discovery of errors is unlikely to depend on treatment group, as expected in blinded trials. Greater transparency is needed in the reporting of stratification errors and how they were addressed in the analysis.
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Affiliation(s)
- Lisa N. Yelland
- Women and Kids ThemeSouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
- School of Public HealthThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Jennie Louise
- Adelaide Medical SchoolThe University of AdelaideAdelaideSouth AustraliaAustralia
| | | | | | - Katherine J. Lee
- Clinical Epidemiology and Biostatistics UnitMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia
| | - Thomas R. Sullivan
- Women and Kids ThemeSouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
- School of Public HealthThe University of AdelaideAdelaideSouth AustraliaAustralia
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Nugent M, Bryant V, Butcher C, Fisher H, Gill S, Goranova R, Hiu S, Lindley L, O'Hara J, Oluboyede Y, Patterson J, Rapley T, Robinson T, Rousseau N, Ryan V, Shanmugasundaram R, Sharp L, Smith Whelan R, Stocken DD, Ternent L, Wilson J, Walker J. Photobiomodulation in the management of oral mucositis for adult head and neck cancer patients receiving irradiation: the LiTEFORM RCT. Health Technol Assess 2022; 26:1-172. [PMID: 36484364 PMCID: PMC9761526 DOI: 10.3310/uwnb3375] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Oral mucositis is a debilitating and painful complication of head and neck cancer irradiation that is characterised by inflammation of the mucous membranes, erythema and ulceration. Oral mucositis affects 6000 head and neck cancer patients per year in England and Wales. Current treatments have not proven to be effective. International studies suggest that low-level laser therapy may be an effective treatment. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of low-level laser therapy in the management of oral mucositis in head and neck cancer irradiation. To identify barriers to and facilitators of implementing low-level laser therapy in routine care. DESIGN Placebo-controlled, individually randomised, multicentre Phase III superiority trial, with an internal pilot and health economic and qualitative process evaluations. The participants, outcome assessors and therapists were blinded. SETTING Nine NHS head and neck cancer sites in England and Wales. PARTICIPANTS A total of 87 out of 380 participants were recruited who were aged ≥ 18 years and were undergoing head and neck cancer irradiation with ≥ 60 Gy. INTERVENTION Random allocation (1 : 1 ratio) to either low-level laser therapy or sham low-level laser therapy three times per week for the duration of irradiation. The diode laser had the following specifications: wavelength 660 nm, power output 75 mW, beam area 1.5 cm2, irradiance 50 mW/cm2, exposure time 60 seconds and fluence 3 J/cm2. There were 20-30 spots per session. Sham low-level laser therapy was delivered in an identical manner. MAIN OUTCOME MEASURE The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks following the start of irradiation. Higher scores indicate a worse outcome. RESULTS A total of 231 patients were screened and, of these, 87 were randomised (low-level laser therapy arm, n = 44; sham arm, n = 43). The mean age was 59.4 years (standard deviation 8.8 years) and 69 participants (79%) were male. The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks was 33.2 (standard deviation 10) in the low-level laser therapy arm and 27.4 (standard deviation 13.8) in the sham arm. LIMITATIONS The trial lacked statistical power because it did not meet the recruitment target. Staff and patients willingly participated in the trial and worked hard to make the LiTEFORM trial succeed. However, the task of introducing, embedding and sustaining new low-level laser therapy services into a complex care pathway proved challenging. Sites could deliver low-level laser therapy to only a small number of patients at a time. The administration of low-level laser therapy was viewed as straightforward, but also time-consuming and sometimes uncomfortable for both patients and staff, particularly those staff who were not used to working in a patient's mouth. CONCLUSIONS This trial had a robust design but lacked power to be definitive. Low-level laser therapy is relatively inexpensive. In contrast with previous trials, some patients found low-level laser therapy sessions to be difficult. The duration of low-level laser therapy sessions is, therefore, an important consideration. Clinicians experienced in oral cavity work most readily adapt to delivering low-level laser therapy, although other allied health professionals can be trained. Blinding the clinicians delivering low-level laser therapy is feasible. There are important human resource, real estate and logistical considerations for those setting up low-level laser therapy services. FUTURE WORK Further well-designed randomised controlled trials investigating low-level laser therapy in head and neck cancer irradiation are needed, with similar powered recruitment targets but addressing the recruitment challenges and logistical findings from this research. TRIAL REGISTRATION This trial is registered as ISRCTN14224600. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 46. See the NIHR Journals Library website for further project information.
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M F, K D, M L, PS H, S A, R S, E V, D G, L G, R L, K M, GD M, L N, C R, A ST, A C, S K, Laird B. An international open-label randomised trial comparing a two-step approach versus the standard three-step approach of the WHO analgesic ladder in patients with cancer. Ann Oncol 2022; 33:1296-1303. [PMID: 36055465 DOI: 10.1016/j.annonc.2022.08.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Worldwide, cancer pain management follows the World Health Organization (WHO) three-step analgesic ladder. Using weak opioids (e.g. codeine) at step 2 is debatable with low-dose strong opioids being potentially better, particularly in low- and middle-income countries where weak opioids are expensive. We wanted to assess the efficiency, safety and cost of omitting step 2 of the WHO ladder. PATIENTS AND METHODS We carried out an international, open-label, randomised (1 : 1) parallel group trial. Eligible patients had cancer, pain ≥4/10 on a 0-10 numerical rating scale, required at least step 1 (paracetamol) of the WHO ladder and were randomised to the control arm (weak opioid, step 2 of the WHO ladder) or the experimental arm (strong opioid, step 3). Primary outcome was time to stable pain control (3 consecutive days with pain ≤3). Secondary outcomes included distress, opioid-related side-effects and costs. The primary outcome analysis was by intention to treat and the follow-up was for 20 days. RESULTS One hundred and fifty-three patients were randomised (76 control, 77 experimental). There was no statistically significant difference in time to stable pain control between the arms, P = 0.667 (log-rank test). The adjusted hazard ratio for the control arm was 1.03 (95% confidence interval 0.72-1.49). In the control arm, 38 patients (53%) needed to change to a strong opioid due to ineffective analgesia. The median time to change was day 6 (interquartile range 4-11). Compared to the control arm, patients in the experimental arm had less nausea (P = 0.009) and costs were less. CONCLUSION This trial provides some evidence that the two-step approach is an alternative option for cancer pain management.
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Beesdo-Baum K, Zenker M, Rückert F, Kische H, Pieper L, Asselmann E. Efficacy of Applied Relaxation as indicated preventive intervention in individuals at increased risk for mental disorders: A randomized controlled trial. Behav Res Ther 2022; 157:104162. [DOI: 10.1016/j.brat.2022.104162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/07/2022] [Accepted: 07/08/2022] [Indexed: 11/02/2022]
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Amiodarone with or without N-Acetylcysteine for the Prevention of Atrial Fibrillation after Thoracic Surgery: A Double-blind, Randomized Trial. Anesthesiology 2022; 136:916-926. [PMID: 35263434 PMCID: PMC9090984 DOI: 10.1097/aln.0000000000004201] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation may identify patients at risk of subsequent atrial fibrillation, with its greater risk of stroke. This study hypothesized that N-acetylcysteine mitigates inflammation and oxidative stress to reduce the incidence of postoperative atrial fibrillation. METHODS In this double-blind, placebo-controlled trial, patients at high risk of postoperative atrial fibrillation scheduled to undergo major thoracic surgery were randomized to N-acetylcysteine plus amiodarone or placebo plus amiodarone. On arrival to the postanesthesia care unit, N-acetylcysteine or placebo intravenous bolus (50 mg/kg) and then continuous infusion (100 mg/kg over the course of 48 h) was administered plus intravenous amiodarone (bolus of 150 mg and then continuous infusion of 2 g over the course of 48 h). The primary outcome was sustained atrial fibrillation longer than 30 s by telemetry (first 72 h) or symptoms requiring intervention and confirmed by electrocardiography within 7 days of surgery. Systemic markers of inflammation (interleukin-6, interleukin-8, tumor necrosis factor α, C-reactive protein) and oxidative stress (F2-isoprostane prostaglandin F2α; isofuran) were assessed immediately after surgery and on postoperative day 2. Patients were telephoned monthly to assess the occurrence of atrial fibrillation in the first year. RESULTS Among 154 patients included, postoperative atrial fibrillation occurred in 15 of 78 who received N-acetylcysteine (19%) and 13 of 76 who received placebo (17%; odds ratio, 1.24; 95.1% CI, 0.53 to 2.88; P = 0.615). The trial was stopped at the interim analysis because of futility. Of the 28 patients with postoperative atrial fibrillation, 3 (11%) were discharged in atrial fibrillation. Regardless of treatment at 1 yr, 7 of 28 patients with postoperative atrial fibrillation (25%) had recurrent episodes of atrial fibrillation. Inflammatory and oxidative stress markers were similar between groups. CONCLUSIONS Dual therapy comprising N-acetylcysteine plus amiodarone did not reduce the incidence of postoperative atrial fibrillation or markers of inflammation and oxidative stress early after major thoracic surgery, compared with amiodarone alone. Recurrent atrial fibrillation episodes are common among patients with postoperative atrial fibrillation within 1 yr of major thoracic surgery. EDITOR’S PERSPECTIVE
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Trial and error: challenges conducting pragmatic trials in general practice. Br J Gen Pract 2022; 72:54-55. [PMID: 35091399 PMCID: PMC8813103 DOI: 10.3399/bjgp22x718289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Dwyer CP, McAneney H, Rogers FM, Joyce R, Hynes SM. Exploring the impact of ineligibility on individuals expressing interest in a trial aimed at improving daily functioning regarding perceptions of self, research and likelihood of future participation. BMC Med Res Methodol 2021; 21:264. [PMID: 34837941 PMCID: PMC8627622 DOI: 10.1186/s12874-021-01464-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background Eligibility guidelines in research trials are necessary to minimise confounds and reduce bias in the interpretation of potential treatment effects. There is limited extant research investigating how being deemed ineligible for such trials might impact patients’ perceptions of themselves and of research. Better understanding of the impact of patient ineligibility could enhance design and implementation of future research studies. Methods Eight semi-structured telephone interviews were conducted to explore the impact of ineligibility on self-perceptions; perceptions regarding the nature of research; and the likelihood of expressing interest in future research. Data were collected and analysed thematically through inductive, interpretive phenomenological analysis (IPA). Results Five themes emerged regarding the experience of being deemed ineligible: (1) Being deemed ineligible is emotion and reaction evoking; (2) ‘Doing your bit’: Helping others and increasing the value of research; (3) Communication of ineligibility; (4) Appreciation for those who express interest; and (5) Subsequent perceptions and attitudes towards research. Conclusions The results suggest that being deemed ineligible can elicit negative emotional outcomes but is not likely to change perceptions of or attitudes towards research, possibly due to a desire to help similar others. Ineligibility can impact future participation in some cases, thus reducing the recruitment pool for subsequent research studies. Recommendations are provided to help minimise this risk. Advising of ineligibility in a personal way is recommended: with enhanced clarity regarding the reasoning behind the decision; providing opportunities to ask questions; and ensuring that appreciation for the patient’s time and interest are communicated.
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Affiliation(s)
- Christopher P Dwyer
- Applied Psychology, School of Social Sciences, Technological University of the Shannon, Athlone, Ireland.
| | - Helen McAneney
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Fionnuala M Rogers
- School of Health Sciences, National University of Ireland, Galway, Ireland
| | - Robert Joyce
- School of Health Sciences, National University of Ireland, Galway, Ireland
| | - Sinéad M Hynes
- School of Health Sciences, National University of Ireland, Galway, Ireland
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Cragg WJ, McMahon K, Oughton JB, Sigsworth R, Taylor C, Napp V. Clinical trial recruiters' experiences working with trial eligibility criteria: results of an exploratory, cross-sectional, online survey in the UK. Trials 2021; 22:736. [PMID: 34689802 PMCID: PMC8542410 DOI: 10.1186/s13063-021-05723-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Eligibility criteria are a fundamental element of clinical trial design, defining who can and who should not participate in a trial. Problems with the design or application of criteria are known to occur and pose risks to participants' safety and trial integrity, sometimes also negatively impacting on trial recruitment and generalisability. We conducted a short, exploratory survey to gather evidence on UK recruiters' experiences interpreting and applying eligibility criteria and their views on how criteria are communicated and developed. METHODS Our survey included topics informed by a wider programme of work at the Clinical Trials Research Unit, University of Leeds, on assuring eligibility criteria quality. Respondents were asked to answer based on all their trial experience, not only on experiences with our trials. The survey was disseminated to recruiters collaborating on trials run at our trials unit, and via other mailing lists and social media. The quantitative responses were descriptively analysed, with inductive analysis of free-text responses to identify themes. RESULTS A total of 823 eligible respondents participated. In total, 79% of respondents reported finding problems with eligibility criteria in some trials, and 9% in most trials. The main themes in the types of problems experienced were criteria clarity (67% of comments), feasibility (34%), and suitability (14%). In total, 27% of those reporting some level of problem said these problems had led to patients being incorrectly included in trials; 40% said they had led to incorrect exclusions. Most respondents (56%) reported accessing eligibility criteria mainly in the trial protocol. Most respondents (74%) supported the idea of recruiter review of eligibility criteria earlier in the protocol development process. CONCLUSIONS Our survey corroborates other evidence about the existence of suboptimal trial eligibility criteria. Problems with clarity were the most often reported, but the number of comments on feasibility and suitability suggest some recruiters feel eligibility criteria and associated assessments can hinder recruitment to trials. Our proposal for more recruiter involvement in protocol development has strong support and some potential benefits, but questions remain about how best to implement this. We invite other trialists to consider our other suggestions for how to assure quality in trial eligibility criteria.
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Affiliation(s)
- William J Cragg
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Jamie B Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Rachel Sigsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Christopher Taylor
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Vicky Napp
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
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A Method to Estimate the Efficacy vs. Effectiveness in Meta-Analysis of Clinical Trials with Different Adherence Scenarios: A Monte Carlo Simulation Study in Nutrition. Nutrients 2021; 13:nu13072352. [PMID: 34371861 PMCID: PMC8308700 DOI: 10.3390/nu13072352] [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: 05/18/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/13/2022] Open
Abstract
Randomized clinical trials (RCTs) evaluating the effectiveness of interventions to promote fruit and vegetable (FV) consumption usually report intention-to-treat (ITT) analysis as the main outcome. These analyses compare the randomly assigned groups and accept that some individuals may not follow the recommendations received in their group. The ITT analysis is useful to quantify the global effect of promoting the consumption of FV in a population (effectiveness) but, if non-adherence is significant in the RCT, they cannot estimate the specific effect in the individuals that increased their FV consumption (efficacy). To calculate the efficacy of FV consumption, a per protocol analysis (PP) would have to be carried out, in which groups of individuals are compared according to their actual adherence to FV consumption, regardless of the group to which they were assigned; unfortunately, many RCTs do not report the PP analysis. The objective of this article is to apply a new method to estimate the efficacy of Meta-analysis (MA) PP which include RCTs of effectiveness by ITT, without estimates of adherence. The method is based on generating Monte Carlo simulations of percentages of adherence in each allocation group from prior distributions informed by expert knowledge. We illustrate the method reanalyzing a Cochrane Systematic Review (SR) of RCTs on increased FV consumption reported with ITT, simulating 1000 times the estimation of a PP meta-analyses, and obtaining means and ranges of the potential PP effects. In some cases, the range of estimated PP effects was clearly more favourable than the effect calculated with the original ITT assumption, and therefore this corrected analysis must be considered when estimating the true effect of the consumption of a certain food.
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Murray M, Dordevic AL, Cox K, Scholey A, Ryan L, Bonham MP. Twelve weeks' treatment with a polyphenol-rich seaweed extract increased HDL cholesterol with no change in other biomarkers of chronic disease risk in overweight adults: A placebo-controlled randomized trial. J Nutr Biochem 2021; 96:108777. [PMID: 34015499 DOI: 10.1016/j.jnutbio.2021.108777] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 11/25/2020] [Accepted: 05/07/2021] [Indexed: 12/19/2022]
Abstract
Cardiovascular diseases (CVD) are the leading global cause of death. Strategies to reduce CVD risk are urgently needed. Polyphenols represent a class of bioactive compounds with potential to moderate biochemical risk factors for CVD (cholesterol, triglycerides, glucose, and inflammation). This double-blind, placebo-controlled, randomized parallel-groups trial investigated the effect of a polyphenol-rich seaweed (Fucus vesiculosus) extract on biochemical markers of CVD risk. Thirty-four overweight and obese adults (21 female, 13 male) with elevated low-density lipoprotein cholesterol (>2.0 mmol/L) were randomized to either the seaweed extract (2000 mg/d) or placebo for twelve weeks. Fasting blood samples were collected at baseline, week six and week twelve to assess biochemical markers. Tests of cognitive performance and mood were performed at baseline, week six and week twelve. A 9.5% (-2.3, 12.9) increase in high-density lipoprotein (HDL) cholesterol was identified following the seaweed extract (baseline: mean (SD) 1.28 (0.23) mmol/L, week 12: 1.35 (0.24) mmol/L) which was different to placebo (baseline: 1.38 (0.54) mmol/L, week 12: 1.35 (0.59) mmol/L) (P=.045). No changes were identified in low-density lipoprotein cholesterol, total cholesterol, triglycerides, glucose, insulin, interleukin (IL)-2, IL-6, IL-8, IL-10, or tumour necrosis factor-alpha levels in the blood, or in cognitive performance or mood between the treatment and placebo groups. Despite the small increase observed in HDL cholesterol, the polyphenol-rich seaweed extract did not change CVD risk factors in adults with high fasting lipids. A larger sample size would be required to confirm the clinical relevance of the changes in HDL cholesterol.
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Affiliation(s)
- Margaret Murray
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Australia; School of Chemistry, Monash University, Clayton, Australia.
| | - Aimee L Dordevic
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Australia.
| | - Kate Cox
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Australia.
| | - Andrew Scholey
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Australia; Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Australia.
| | - Lisa Ryan
- Department of Natural Sciences, Galway-Mayo Institute of Technology, Galway, Ireland.
| | - Maxine P Bonham
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Australia.
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15
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Chu KH, Sidani J, Matheny S, Rothenberger SD, Miller E, Valente T, Robertson L. Implementation of a cluster randomized controlled trial: Identifying student peer leaders to lead E-cigarette interventions. Addict Behav 2021; 114:106726. [PMID: 33278717 PMCID: PMC7785638 DOI: 10.1016/j.addbeh.2020.106726] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/26/2020] [Accepted: 11/01/2020] [Indexed: 11/28/2022]
Abstract
E-cigarette use has been increasing among middle school students. Intervention programs to prevent e-cigarette initiation administered by authority figures are met with more resistance from youth compared to peer-led programs. Therefore, this study aimed to assess the feasibility, acceptability, and implementation process of using social network analysis (SNA) to identify student peer leaders in schools and train them to deliver e-cigarette prevention programming to their peers. Nine schools were recruited to participate in the study during the 2019-2020 school year. Schools were assigned to one of three conditions: (1) expert; (2) peer-random (selected peer-leaders would teach to random students); and (3) peer-fixed (selected peer-leaders would teach to assigned students based on nominations). Study participation varied by day due to school attendance, with 686 participants at baseline and 608 at posttest. Almost all students who did not complete the study resulted from the interruption of schools being closed due to COVID-19. Implementation issues fell into three categories: (1) scheduling, (2) day-of logistics, and (3) student group dynamics. Overall, the results showed positive satisfaction among teachers, who unanimously found the program appropriate for the grade-level and that peer-leaders worked well within their groups. Peer-led students-both random and assigned-reported having more fun and willing to tell friends to try the program compared to expert-led students. This study demonstrated the feasibility of implementing a peer-led e-cigarette prevention program for 6th grade students, using SNA to provide intervention rigidity and validity.
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Mueller S, Winzer EB, Duvinage A, Gevaert AB, Edelmann F, Haller B, Pieske-Kraigher E, Beckers P, Bobenko A, Hommel J, Van de Heyning CM, Esefeld K, von Korn P, Christle JW, Haykowsky MJ, Linke A, Wisløff U, Adams V, Pieske B, van Craenenbroeck EM, Halle M. Effect of High-Intensity Interval Training, Moderate Continuous Training, or Guideline-Based Physical Activity Advice on Peak Oxygen Consumption in Patients With Heart Failure With Preserved Ejection Fraction: A Randomized Clinical Trial. JAMA 2021; 325:542-551. [PMID: 33560320 PMCID: PMC7873782 DOI: 10.1001/jama.2020.26812] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Endurance exercise is effective in improving peak oxygen consumption (peak V̇o2) in patients with heart failure with preserved ejection fraction (HFpEF). However, it remains unknown whether differing modes of exercise have different effects. OBJECTIVE To determine whether high-intensity interval training, moderate continuous training, and guideline-based advice on physical activity have different effects on change in peak V̇o2 in patients with HFpEF. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 5 sites (Berlin, Leipzig, and Munich, Germany; Antwerp, Belgium; and Trondheim, Norway) from July 2014 to September 2018. From 532 screened patients, 180 sedentary patients with chronic, stable HFpEF were enrolled. Outcomes were analyzed by core laboratories blinded to treatment groups; however, the patients and staff conducting the evaluations were not blinded. INTERVENTIONS Patients were randomly assigned (1:1:1; n = 60 per group) to high-intensity interval training (3 × 38 minutes/week), moderate continuous training (5 × 40 minutes/week), or guideline control (1-time advice on physical activity according to guidelines) for 12 months (3 months in clinic followed by 9 months telemedically supervised home-based exercise). MAIN OUTCOMES AND MEASURES Primary end point was change in peak V̇o2 after 3 months, with the minimal clinically important difference set at 2.5 mL/kg/min. Secondary end points included changes in metrics of cardiorespiratory fitness, diastolic function, and natriuretic peptides after 3 and 12 months. RESULTS Among 180 patients who were randomized (mean age, 70 years; 120 women [67%]), 166 (92%) and 154 (86%) completed evaluation at 3 and 12 months, respectively. Change in peak V̇o2 over 3 months for high-intensity interval training vs guideline control was 1.1 vs -0.6 mL/kg/min (difference, 1.5 [95% CI, 0.4 to 2.7]); for moderate continuous training vs guideline control, 1.6 vs -0.6 mL/kg/min (difference, 2.0 [95% CI, 0.9 to 3.1]); and for high-intensity interval training vs moderate continuous training, 1.1 vs 1.6 mL/kg/min (difference, -0.4 [95% CI, -1.4 to 0.6]). No comparisons were statistically significant after 12 months. There were no significant changes in diastolic function or natriuretic peptides. Acute coronary syndrome was recorded in 4 high-intensity interval training patients (7%), 3 moderate continuous training patients (5%), and 5 guideline control patients (8%). CONCLUSIONS AND RELEVANCE Among patients with HFpEF, there was no statistically significant difference in change in peak V̇o2 at 3 months between those assigned to high-intensity interval vs moderate continuous training, and neither group met the prespecified minimal clinically important difference compared with the guideline control. These findings do not support either high-intensity interval training or moderate continuous training compared with guideline-based physical activity for patients with HFpEF. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02078947.
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Affiliation(s)
- Stephan Mueller
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Ephraim B. Winzer
- Heart Center Dresden–University Hospital, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
| | - André Duvinage
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Andreas B. Gevaert
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Paul Beckers
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Anna Bobenko
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Jennifer Hommel
- Heart Center Dresden–University Hospital, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
| | - Caroline M. Van de Heyning
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Katrin Esefeld
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Pia von Korn
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Jeffrey W. Christle
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Mark J. Haykowsky
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Axel Linke
- Heart Center Dresden–University Hospital, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
| | - Ulrik Wisløff
- The Cardiac Exercise Research Group at Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Volker Adams
- Heart Center Dresden–University Hospital, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Emeline M. van Craenenbroeck
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Martin Halle
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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Lawton B, Storey F, Sibanda N, Bennett M, Lambert C, Geller S, Edmonds L, Cram F. He Korowai Manaaki (Pregnancy Wraparound Care): Protocol for a Cluster Randomized Clinical Trial. JMIR Res Protoc 2021; 10:e18154. [PMID: 33512321 PMCID: PMC7880808 DOI: 10.2196/18154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 10/01/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022] Open
Abstract
Background Maternal and infant health inequities between Māori (the Indigenous peoples of Aotearoa New Zealand) and New Zealand European women are well documented and cannot be explained solely by socioeconomic status. A research center-iwi (tribal group) partnership aims to address these disparities and improve maternal and infant health outcomes by implementing an augmented maternity care pathway (He Korowai Manaaki) to improve access to services and evidence-informed care. Objective The objective of this study is to test whether an augmented maternity care pathway improves Māori infant health outcomes. Methods This is a Kaupapa Māori (by, with, and for Māori) cluster randomized clinical trial involving 8 primary care practices allocated to either an intervention arm or control arm. The intervention arm comprises an augmented maternity care pathway (He Korowai Manaaki) offering clinical care through additional paid health care appointments and improved access to social support (eg, housing, transport). The control arm is usual care. The primary outcome is increased timely vaccination for Māori infants, defined as all age-appropriate vaccinations completed by 6 months of age. Results Recruitment commenced in November 2018 and was completed in June 2020, with 251 enrolled women recruited in intervention primary care practices before 20 weeks of pregnancy. Publication of results is anticipated in late 2023. Conclusions The results will inform primary health care policy including whether the provision of augmented maternal care pathways reduces disparities in the structural determinants of health. If effective, He Korowai Manaaki will strengthen the health and well-being of pregnant Māori women and their babies and improve their health outcomes, laying a strong foundation for lifelong health and well-being. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12619001155189; https://tinyurl.com/yypbef8q International Registered Report Identifier (IRRID) DERR1-10.2196/18154
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Affiliation(s)
- Beverley Lawton
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Francesca Storey
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Nokuthaba Sibanda
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Matthew Bennett
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Charles Lambert
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Stacie Geller
- Center for Research on Women & Gender, Center of Excellence in Women's Health, Department of Obstetrics and Gynaecology, University of Illinois, Chicago, IL, United States
| | - Liza Edmonds
- Women's & Children's Health, University of Otago, Dunedin, New Zealand
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Rehman AM, Ferrand R, Allen E, Simms V, McHugh G, Weiss HA. Exclusion of enrolled participants in randomised controlled trials: what to do with ineligible participants? BMJ Open 2020; 10:e039546. [PMID: 33268410 PMCID: PMC7713189 DOI: 10.1136/bmjopen-2020-039546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Post-randomisation exclusions in randomised controlled trials are common and may include participants identified as not meeting trial eligibility criteria after randomisation. We report how a decision might be reached and reported on, to include or exclude these participants. We illustrate using a motivating scenario from the BREATHE trial (Trial registration ClinicalTrials.gov, NCT02426112) evaluating azithromycin for the treatment of chronic lung disease in people aged 6-19 years with HIV in Zimbabwe and Malawi. KEY POINTS Including all enrolled and randomised participants in the primary analysis of a trial ensures an unbiased estimate of the intervention effect using intention-to-treat principles, and minimises the effects of confounding through balanced allocation to trial arm. Ineligible participants are sometimes enrolled, due to measurement or human error. Of 347 participants enrolled into the BREATHE trial, 11 (3.2%) were subsequently found to be ineligible based on lung function criteria. We assumed no safety risk of azithromycin treatment; their inclusion in the trial and subsequent analysis of the intervention effect therefore mirrors clinical practice. Senior trial investigators considered diurnal variations in the measurement of lung function, advantages of retaining a higher sample size and advice from the Data Safety and Monitoring Board and Trial Steering Committee, and decided to include these participants in primary analysis. We planned and reported analyses including and excluding these participants, and in our case the interpretation of treatment effect was consistent. CONCLUSION The decision, by senior investigators, on whether to exclude enrolled participants, should reflect issues of safety, treatment efficacy, statistical power and measurement error. As long as decisions are made prior to finalising the statistical analysis plan for the trial, the risk of exclusions creating bias should be minimal. The decision taken should be transparently reported and a sensitivity analysis can present the opposite decision.
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Affiliation(s)
- Andrea M Rehman
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Rashida Ferrand
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Victoria Simms
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Grace McHugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Helen Anne Weiss
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
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DeSantis SM, Li R, Zhang Y, Wang X, Vernon SW, Tilley BC, Koch G. Intent-to-treat analysis of cluster randomized trials when clusters report unidentifiable outcome proportions. Clin Trials 2020; 17:627-636. [DOI: 10.1177/1740774520936668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Cluster randomized trials are designed to evaluate interventions at the cluster or group level. When clusters are randomized but some clusters report no or non-analyzable data, intent-to-treat analysis, the gold standard for the analysis of randomized controlled trials, can be compromised. This article presents a very flexible statistical methodology for cluster randomized trials whose outcome is a cluster-level proportion (e.g. proportion from a cluster reporting an event) in the setting where clusters report non-analyzable data (which in general could be due to nonadherence, dropout, missingness, etc.). The approach is motivated by a previously published stratified randomized controlled trial called, “The Randomized Recruitment Intervention Trial (RECRUIT),” designed to examine the effectiveness of a trust-based continuous quality improvement intervention on increasing minority recruitment into clinical trials (ClinicalTrials.gov Identifier: NCT01911208). Methods The novel approach exploits the use of generalized estimating equations for cluster-level reports, such that all clusters randomized at baseline are able to be analyzed, and intervention effects are presented as risk ratios. Simulation studies under different outcome missingness scenarios and a variety of intra-cluster correlations are conducted. A comparative analysis of the method with imputation and per protocol approaches for RECRUIT is presented. Results Simulation results show the novel approach produces unbiased and efficient estimates of the intervention effect that maintain the nominal type I error rate. Application to RECRUIT shows similar effect sizes when compared to the imputation and per protocol approach. Conclusion The article demonstrates that an innovative bivariate generalized estimating equations framework allows one to implement an intent-to-treat analysis to obtain risk ratios or odds ratios, for a variety of cluster randomized designs.
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Affiliation(s)
- Stacia M DeSantis
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ruosha Li
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yefei Zhang
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xueying Wang
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sally W Vernon
- Department of Health Promotions and Behavioral Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Barbara C Tilley
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gary Koch
- Department of Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Mohamadi M, Rojhani-Shirazi Z, Assadsangabi R, Rahimi-Jaberi A. Can the Positional Release Technique Affect Central Sensitization in Patients With Chronic Tension-Type Headache? A Randomized Clinical Trial. Arch Phys Med Rehabil 2020; 101:1696-1703. [PMID: 32673652 DOI: 10.1016/j.apmr.2020.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 05/28/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate whether the positional release technique (PRT) affects central sensitization in patients with chronic tension-type headache (TTH). DESIGN Randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. SETTING Two university neurology clinics. PARTICIPANTS Patients (N=32) with TTH and myofascial trigger points (MTrP) in their cervical muscles. INTERVENTIONS Patients in the PRT group received 10 treatment sessions for each of their MTrPs over the course of 5 weeks. All participants could use ibuprofen 200 mg for their headaches during the study. MAIN OUTCOME MEASURES The primary outcome measure was brain metabolite profile. The secondary outcome measures were headache frequency and intensity, McGill score, and pressure pain threshold (PPT), which were evaluated in each participant during 5 weeks with proton magnetic resonance spectroscopy, patients' self-reports, the McGill Pain Questionnaire, and a pressure algometer. RESULTS Analysis of the data from 26 patients showed that headache frequency (P=.001), headache intensity (P=.002), McGill score (P=.003), and local PPT (P=.003) changed significantly after PRT. The myo-inositol/creatine concentration ratio in the somatosensory cortex (P=.041) decreased significantly in the control group. Furthermore, there were significant differences between groups in headache frequency (P<.001), headache intensity (P<.001), McGill score (P<.001), local PPT (P=.004), distal PPT (P=.041), and glutamate-glutamine/creatine concentration ratio in the thalamus (P=.014). CONCLUSIONS These findings indicate that PRT did not affect central sensitization in patients with TTH despite the improvement in clinical symptoms.
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Affiliation(s)
- Marzieh Mohamadi
- Rehabilitation Research Center, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Rojhani-Shirazi
- Rehabilitation Research Center, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Reza Assadsangabi
- Department of Radiology, Davis School of Medicine, University of California, Sacramento, CA
| | - Abbas Rahimi-Jaberi
- Department of Neurology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Hypertonic saline for fluid resuscitation in ICU patients post-cardiac surgery (HERACLES): a double-blind randomized controlled clinical trial. Intensive Care Med 2020; 46:1683-1695. [PMID: 32519005 DOI: 10.1007/s00134-020-06132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Recent evidence questions a liberal approach to fluid resuscitation in intensive care unit (ICU) patients. Here, we assess whether use of hypertonic saline applied as single infusion at ICU admission after cardiac surgery can reduce cumulative perioperative fluid volume. METHODS Prospective randomized double-blind single-center clinical trial investigates effects of a single infusion of hypertonic saline (HS) versus normal saline (comparator). Primary endpoint was the cumulative amount of fluid administered in patients in the hypertonic saline versus the 0.9% saline groups (during ICU stay). Upon ICU admission, patients received a single infusion of 5 ml/kg body weight of 7.3% NaCl (or 0.9% NaCl) over 60 min. Patients undergoing cardiac surgery for elective valvular and/or coronary heart disease were included. Patients with advanced organ dysfunction, infection, and/or patients on chronic steroid medication were excluded. RESULTS A total of 101 patients were randomized to receive the study intervention (HS n = 53, NS n = 48). Cumulative fluid intake on the ICU (primary endpoint) did not differ between the HS and the NS groups [median 3193 ml (IQR 2052-4333 ml) vs. 3345 ml (IQR 2332-5043 ml)]. Postoperative urinary output until ICU discharge was increased in HS-treated patients [median 2250 ml (IQR 1640-2690 ml) vs. 1545 ml (IQR 1087-1976 ml)], and ICU fluid balance was lower in the HS group when compared to the NS group [296 ml (IQR - 441 to 1412 ml) vs. 1137 ml (IQR 322-2660 ml)]. CONCLUSION In a monocentric prospective double-blind randomized clinical trial, we observed that hypertonic saline did not reduce the total fluid volume administered on the ICU in critically ill cardiac surgery patients. Hypertonic saline infusion was associated with timely increase in urinary output. Variations in electrolyte and acid-base homeostasis were transient, but substantial in all patients.
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Valesky W, Chow L. Prone Positioning for Acute Respiratory Distress Syndrome in Adults. Acad Emerg Med 2020; 27:520-522. [PMID: 32096893 DOI: 10.1111/acem.13948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/19/2020] [Accepted: 02/22/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Walter Valesky
- From the Department of Emergency Medicine Kings County Hospital—NYC Health + Hospitals Brooklyn NY
| | - Lillian Chow
- and the Department of Medicine Division of Pulmonary and Critical Care Medicine SUNY Downstate Health Sciences University Brooklyn NY
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Loevaas MES, Lydersen S, Sund AM, Neumer SP, Martinsen KD, Holen S, Patras J, Adolfsen F, Rasmussen LMP, Reinfjell T. A 12-month follow-up of a transdiagnostic indicated prevention of internalizing symptoms in school-aged children: the results from the EMOTION study. Child Adolesc Psychiatry Ment Health 2020; 14:15. [PMID: 32336987 PMCID: PMC7178617 DOI: 10.1186/s13034-020-00322-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 04/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Anxious and depressive symptoms in youth are highly prevalent, are often comorbid and have a high rate of relapse. Preventive interventions are promising, but follow-up results are lacking. The transdiagnostic EMOTION program is an indicated preventive cognitive behavioral therapy (CBT) intervention targeting children aged 8-12 years. METHODS The present study investigates the 12 months follow-up effects of the EMOTION intervention in a cluster randomized controlled trial (RCT) with 795 children that included both child self-reports and parental reports. RESULTS Mixed model analyses showed a larger decrease of symptoms in the intervention group than in the control group for child self-reported anxious symptoms (The Multidimensional Anxiety Scale for Children (MASC) difference 4.56, CI 1.83 to 7.29, p = .001). Parental reports for both anxious (MASC difference 2.50, CI .26 to 4.74, p = .029) and depressive (The Mood and Feelings Questionnaire-short form (SMFQ) difference 1.55, CI .83 to 2.26, p ≤ .001) symptoms in children also showed a reduction. No statistically significant difference was found for child self-reported depressive symptoms (SMFQ difference .69, CI - .22 to 1.60, p = .139). CONCLUSION The transdiagnostic EMOTION program has shown the potential for long-term reductions in symptoms of both anxiety and depression in school-aged children. However, results regarding depressive symptoms must be considered preliminary as only parental report indicated effect.Trial registration The regional ethics committee (REC) of Norway approved the study. Registration number: 2013/1909; Project title: Coping Kids: a randomized controlled study of a new indicated preventive intervention for children with symptoms of anxiety and depression. ClinicalTrials.gov Identifier; NCT02340637.
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Affiliation(s)
- M. E. S. Loevaas
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
| | - S. Lydersen
- Medical Faculty, Department of Mental Health, Regional Center for Child and Youth Mental Health and Child Welfare, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - A. M. Sund
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
- Medical Faculty, Department of Mental Health, Regional Center for Child and Youth Mental Health and Child Welfare, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - S-P. Neumer
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - K. D. Martinsen
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - S. Holen
- Centre for Child and Adolescent Mental Health, RBUP East and South, Oslo, Norway
| | - J. Patras
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT Arctic University of Norway, Tromsø, Norway
| | - F. Adolfsen
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT Arctic University of Norway, Tromsø, Norway
| | - L-M. P. Rasmussen
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT Arctic University of Norway, Tromsø, Norway
| | - T. Reinfjell
- Department of Psychology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
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Fredborg C, Odgaard A, Sørensen J. Patellofemoral arthroplasty is cheaper and more effective in the short term than total knee arthroplasty for isolated patellofemoral osteoarthritis: cost-effectiveness analysis based on a randomized trial. Bone Joint J 2020; 102-B:449-457. [PMID: 32228074 DOI: 10.1302/0301-620x.102b4.bjj-2018-1580.r3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS The aim is to assess the cost-effectiveness of patellofemoral arthroplasty (PFA) in comparison with total knee arthroplasty (TKA) for the treatment of isolated patellofemoral osteoarthritis (OA) based on prospectively collected data on health outcomes and resource use from a blinded, randomized, clinical trial. METHODS A total of 100 patients with isolated patellofemoral osteoarthritis were randomized to receive either PFA or TKA by experienced knee surgeons trained in using both implants. Patients completed patient-reported outcomes including EuroQol five-dimension questionnaire (EQ-5D) and 6-Item Short-Form Health Survey questionnaire (SF-6D) before the procedure. The scores were completed again after six weeks, three, six, and nine months, and again after one- and two-year post-surgery and yearly henceforth. Time-weighted outcome measures were constructed. Cost data were obtained from clinical registrations and patient-reported questionnaires. Incremental gain in health outcomes (quality-adjusted life-years (QALYs)) and incremental costs were compared for the two groups of patients. Net monetary benefit was calculated assuming a threshold value of €10,000, €35,000, and €50,000 per QALY and used to test the statistical uncertainty and central assumptions about outcomes and costs. RESULTS The PFA group had an incremental 12 month EQ-5D gain of 0.056 (95% confidence interval (CI) 0.01 to 0.10) and an incremental 12 month cost of minus €328 (95% CI 836 to 180). PFA therefore dominates TKA by providing better and cheaper outcomes than TKA. The net monetary benefit of PFA was €887 (95% CI 324 to 1450) with the €10,000 threshold, and it was consistently positive when different measures of outcomes and different cost assumptions were used. CONCLUSION This study provides robust evidence that PFA from a one-year hospital management perspective is cheaper and provides better outcomes than TKA when applied to patients with isolated patellofemoral osteoarthritis and performed by experienced knee surgeons. Cite this article: Bone Joint J 2020;102-B(4):449-457.
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Affiliation(s)
- Charlotte Fredborg
- Copenhagen University Hospital Herlev-Gentofte, Rigshospitalet-Glostrup, Hellerup, Copenhagen, Denmark.,Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Anders Odgaard
- Copenhagen University Hospital Herlev-Gentofte and Rigshospitalet, Hellerup, Copenhagen, Denmark
| | - Jan Sørensen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense C, Denmark.,Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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Coughlan EK, Williams AM, Ford PR. Lessons From the Experts: The Effect of a Cognitive Processing Intervention During Deliberate Practice of a Complex Task. JOURNAL OF SPORT & EXERCISE PSYCHOLOGY 2019; 41:298-308. [PMID: 31585434 DOI: 10.1123/jsep.2017-0363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 07/02/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023]
Abstract
Deliberate practice is defined as an activity that is highly relevant to improving performance. It is effortful, challenging, not inherently enjoyable, or immediately rewarding and underpinned by advanced cognitive processing. The authors examine the effect of increasing cognitive processing during deliberate practice on skill learning in intermediate-level performers using a novel approach and quasi-experimental design. Two matched groups of intermediate-level Gaelic football players practiced a kick they identified as being most relevant to improving performance during an acquisition phase and pre-, post-, and retention tests. During acquisition, participants rated practice for cognitive effort and enjoyment. An intervention group engaged in structured cognitive processing before, during, and after the kicking practice sessions, whereas a control group did not. Both groups improved kicking accuracy across pre-, post-, and retention tests; however, the intervention group improved accuracy significantly more than the control group. The intervention group rated practice greater for mental effort compared with the control group, while both groups rated practice low for enjoyment. The intervention group increased reflection and evaluation to a greater degree following practice compared with the control group. Findings highlight the value of applying the principles of deliberate practice and increasing cognitive processing to expedite learning in intermediate-level performers, with implications for skill learning across many professional domains.
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Nathan R, Centifanti L, Baker V, Hill J. A pilot randomised controlled trial of a programme of psychosocial interventions (Resettle) for high risk personality disordered offenders. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 66:101463. [PMID: 31706395 DOI: 10.1016/j.ijlp.2019.101463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/04/2019] [Accepted: 06/25/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Offenders with personality disorder experience significant co-morbid mental health problems and present with an increased risk of offending. The evidence for the effectiveness of interventions for personality disordered offenders in the community is limited. This study was a pilot study to determine the feasibility of a randomised controlled trial (RCT) of an intervention known as Resettle for personality disordered offenders and to explore the possible effects of this intervention. METHODS Potential participants were recruited from referrals of male prisoners to Resettle. Those consenting underwent baseline assessments before being randomised to Resettle or treatment as usual. Officially recorded and self-report offending was assessed over two years following release from custody. Of the 110 eligible participants, 72 (65%) participated in the study of whom 38 were randomised to Resettle and 34 to treatment as usual. The two groups had a similar psychiatric and offending profile. RESULTS Analysis of officially recorded offences at two years found mixed results, but whether adopting an intent-to-treat approach or including only those who received the intervention there was no clear evidence of an effect of the intervention. A comparison of self-report offending found no effect of Resettle in an intent-to-treat analysis, but there was an effect when the analysis involved only those participating in the intervention. CONCLUSIONS This study demonstrated that with some adjustments it was possible to carry out an RCT of a complex intervention for personality disordered offenders in a criminal justice setting. Some, but not conclusive, evidence was found in favour of the intervention.
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Affiliation(s)
- Rajan Nathan
- Institute of Population Health Sciences, University of Liverpool, Block B, Waterhouse Building, 1-5 Dover Street, Liverpool L69 3BX, United Kingdom; Cheshire Wirral Partnerships Research Department, Churton House, Countess of Chester Health Park, Parsons Lane, Chester CH2 1HJ, United Kingdom; Chester Medical School, University of Chester, Bache Hall, Chester CH2 1BR, United Kingdom.
| | - Luna Centifanti
- Institute of Life and Human Sciences, Department of Clinical Psychology, University of Liverpool, Whelan Building, Quadrangle, Brownlow Hill, Liverpool L69 3GB, United Kingdom
| | - Vikki Baker
- Mersey Care NHS Trust, Unit 1, 3 de Havilland Drive, International Business Park, Speke, Liverpool L24 8RN, United Kingdom
| | - Jonathan Hill
- University of Reading, Whiteknights, Po Box 217, Reading, Berkshire RG6 6AH, United Kingdom
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Cornet-Vernet L, Munyangi J, Chen L, Towler M, Weathers P. Response to Argemi et al. 2019. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2019; 62:152943. [PMID: 31158695 PMCID: PMC7008389 DOI: 10.1016/j.phymed.2019.152943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/30/2019] [Indexed: 05/26/2023]
Affiliation(s)
- Lucile Cornet-Vernet
- Association More for Less-Maison de l'Artemisia, 20 Rue Pierre Demours, 75017 Paris, France.
| | - Jerome Munyangi
- Faculté de Médecine Université de University, Democratic Republic of the Congo
| | - Lu Chen
- Department of Mathematics, Worcester Polytechnic Institute, USA
| | - Melissa Towler
- Department of Biology and Biotechnology, Worcester Polytechnic Institute, USA
| | - Pamela Weathers
- Department of Biology and Biotechnology, Worcester Polytechnic Institute, USA
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Confirmed Hypoallergenicity of a Novel Whey-Based Extensively Hydrolyzed Infant Formula Containing Two Human Milk Oligosaccharides. Nutrients 2019; 11:nu11071447. [PMID: 31248026 PMCID: PMC6682865 DOI: 10.3390/nu11071447] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/09/2019] [Accepted: 06/17/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We sought to determine whether an extensively hydrolyzed formula (EHF) supplemented with two human milk oligosaccharides (HMO) was tolerated by infants with cow's milk protein allergy (CMPA). METHODS A whey-based EHF (Test formula) containing 2'fucosyl-lactose (2'FL) and lacto-N-neotetraose (LNnT) was assessed for clinical hypoallergenicity and safety. The Control formula was a currently marketed EHF without HMO. Children with CMPA, aged 2 months to 4 years, were assessed by double-blind, placebo-controlled food challenges (DBPCFC) to both formulas, in randomized order. If both DBPCFC were negative, subjects participated in a one-week, open food challenge (OFC) with the Test formula. Symptoms and adverse events were recorded. Hypoallergenicity was accepted if at least 90% (with 95% confidence intervals) of subjects tolerated the Test formula. RESULTS Of the 82 children with CMPA that were screened, 67 (intention-to-treat [ITT] cohort-mean age 24.5 ± 13.6 months; range 2-57; 45 [67.2%] male) were randomized to receive either the Test or the Control formula during the first DBPCFC. Of these, 64 children completed at least one DBPCFC (modified intention-to-treat [mITT] cohort). Three children were excluded due to protocol deviations (per protocol [PP] cohort; n = 61). There was one allergic reaction to the Test, and one to the Control formula. On the mITT analysis, 63 out of 64 (98.4%; 95% CI lower bound 92.8%), and on the PP analysis 60 out of 61 (98.4%; 95% CI lower bound 92.5%) participants tolerated the Test formula, confirming hypoallergenicity. CONCLUSION The whey-based EHF supplemented with 2'FL and LNnT met the clinical hypoallergenicity criteria and can be recommended for the management of CMPA in infants and young children.
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Fluid management in patients undergoing cardiac surgery: effects of an acetate- versus lactate-buffered balanced infusion solution on hemodynamic stability (HEMACETAT). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:159. [PMID: 31060591 PMCID: PMC6503387 DOI: 10.1186/s13054-019-2423-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/08/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Recent evidence suggests that acetate-buffered infusions result in better hemodynamic stabilization than 0.9% saline in patients undergoing major surgery. The choice of buffer in balanced crystalloid solutions may modify their hemodynamic effects. We therefore compared the inopressor requirements of Ringer's acetate and lactate for perioperative fluid management in patients undergoing cardiac surgery. METHODS Using a randomized controlled double-blind design, we compared Ringer's acetate (RA) to Ringer's lactate (RL) with respect to the average rate of inopressor administered until postoperative hemodynamic stabilization was achieved. Secondary outcomes were the cumulative dose of inopressors, the duration of inopressor administration, the total fluid volume administered, and the changes in acid-base homeostasis. Patients undergoing elective valvular cardiac surgery were included. Patients with severe cardiac, renal, or liver disease were excluded from the study. RESULTS Seventy-five patients were randomly allocated to the RA arm, 73 to the RL. The hemodynamic profiles were comparable between the groups. The groups did not differ with respect to the average rate of inopressors (RA 2.1 mcg/kg/h, IQR 0.5-8.1 vs. RL 1.7 mcg/kg/h, IQR 0.7-8.2, p = 0.989). Cumulative doses of inopressors and time on individual and combined inopressors did not differ between the groups. No differences were found in acid-base parameters and their evolution over time. CONCLUSION In this study, hemodynamic profiles of patients receiving Ringer's lactate and Ringer's acetate were comparable, and the evolution of acid-base parameters was similar. These study findings should be evaluated in larger, multi-center studies. TRIAL REGISTRATION Clinicaltrials.gov NCT02895659 . Registered 16 September 2016.
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Open trial of a personalized modular treatment for mood and anxiety. Behav Res Ther 2019; 116:69-79. [DOI: 10.1016/j.brat.2019.01.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 01/05/2019] [Accepted: 01/28/2019] [Indexed: 12/25/2022]
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Honvo G, Bruyère O, Geerinck A, Veronese N, Reginster JY. Efficacy of Chondroitin Sulfate in Patients with Knee Osteoarthritis: A Comprehensive Meta-Analysis Exploring Inconsistencies in Randomized, Placebo-Controlled Trials. Adv Ther 2019; 36:1085-1099. [PMID: 30879253 PMCID: PMC6824370 DOI: 10.1007/s12325-019-00921-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION There are some controversies about treatment modalities in osteoarthritis (OA), including chondroitin sulfate (CS). The objective of this study was to determine whether CS is effective at alleviating pain and improving function in patients with knee OA and to identify the factors that explain inconsistencies in clinical trial results. METHODS We conducted a systematic review of randomized, placebo-controlled trials, searching the databases Medline, Cochrane central register for controlled trials and Scopus. Random effects meta-analysis was then performed, using tau2 and I2 statistics to assess heterogeneity. The pain and Lequesne index (LI) scores were expressed as standardized mean differences (SMDs), with a 95% confidence interval (CI). Heterogeneity was explored by stratifying the analyses according to pre-specified study-level characteristics and assessing the sources of funnel plot asymmetry. RESULTS The inclusion criteria yielded 18 trials. Overall, CS significantly but inconsistently reduced pain (SMD: - 0.63; 95% CI: - 0.91, - 0.35; I2 = 94%) and improved function (SMD: - 0.82; 95% CI: - 1.31, - 0.33; I2 = 95%). When limiting the analysis to studies with a low risk of bias, the pharmaceutical grade CS of IBSA origin showed a greater reduction in pain (SMD: - 0.25; 95% CI: - 0.34, - 0.16; I2 = 75%) and function (SMD: - 0.33; 95% CI: - 0.47, - 0.20; I2 = 53%, p = 0.07) compared with the other preparations (SMDPain: - 0.08; 95% CI: - 0.19, + 0.02; I2 = 20%; SMDFunction: - 0.18; 95% CI: - 0.36, +0.01; I2 = 0%). Assessing funnel plot asymmetry in the studies with a low risk of bias, we found strong correlations between the treatment effects and study size (pain: rS = 0.93; LI: rS = 0.86; p < 0.05). Ultimately, there was no residual heterogeneity in the CS effects when the smallest studies were removed from the analyses. CONCLUSION This new meta-analysis suggests that CS provides a moderate benefit for pain and has a large effect on function in knee OA, however with large inconsistency. The risks of bias, brand and study size were the factors explaining heterogeneity among the clinical trial results.
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Affiliation(s)
- Germain Honvo
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium.
| | - Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Anton Geerinck
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padua, Italy
| | - Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Department of Biochemistry, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Clifton L, Clifton DA. How to maintain the maximal level of blinding in randomisation for a placebo-controlled drug trial. Contemp Clin Trials Commun 2019; 14:100356. [PMID: 31011659 PMCID: PMC6462539 DOI: 10.1016/j.conctc.2019.100356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/25/2019] [Accepted: 04/05/2019] [Indexed: 12/02/2022] Open
Abstract
We illustrate the approach of randomising treatments and compare it with the traditional approach of randomising patients, using a case study drawn from the authors’ experience in clinical trials. The setting is a double-blind parallel two-arm randomised controlled trial (RCT), but the method in this paper can be extended to single-blind, cross-over, or multi-arm RCTs. We propose the concept of two different levels of blinding: full blinding and partial blinding. We subsequently show how to maintain the maximal level of blinding. Using an example, we show that a pharmacist can be fully blinded if the investigational medical products (IMPs) that they prescribe (instead of patients) are randomised, and they can be partially blinded if they need to dispense replacement (i.e., surplus) IMPs. A small number of surplus IMPs is commonly required in a clinical trial to replace lost or damaged IMPs. We note that the concept of full blinding and partial blinding is different from double-blind trial, and the level of blinding is relevant in both single-blind and double-blind trials. A trial statistician needs to work closely with all parties in the design of the randomisation, including the pharmacist, the trial manager, and the manufacturer. We detail what should and should not be shown in the various documents that the trial statistician need to provide to the pharmacist and to the manufacturer. We provide template tables for these documents.
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Affiliation(s)
- Lei Clifton
- Nuffield Department of Population Health (NDPH), University of Oxford, UK
| | - David A Clifton
- Institute of Biomedical Engineering (IBME), Department of Engineering Science, University of Oxford, UK
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Norman RJ, Alvino H, Hull LM, Mol BW, Hart RJ, Kelly TL, Rombauts L. Human growth hormone for poor responders: a randomized placebo-controlled trial provides no evidence for improved live birth rate. Reprod Biomed Online 2019; 38:908-915. [PMID: 30954433 DOI: 10.1016/j.rbmo.2019.02.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/18/2019] [Accepted: 02/05/2019] [Indexed: 01/19/2023]
Abstract
RESEARCH QUESTION Does the addition of human growth hormone (HGH) to an IVF cycle improve the live birth rate in previously documented poor responders to FSH? DESIGN Double-blind, placebo-controlled, randomized clinical trial comparing HGH to placebo in maximal stimulation in an IVF cycle. The study was stopped after 4 years. Women receiving ovarian stimulation in one IVF cycle, having failed to produce more than 5 eggs in a previous cycle with more than 250 IU/day of FSH were included. Basal FSH was ≤15 IU/l, body mass index <33 kg/m2, age <41 years. HGH or placebo were added from the start of the cycle in a double-blinded manner. The primary outcome was live birth rate. MAIN RESULTS The live birth rates following an IVF cycle were 9/62 (14.5%) for growth hormone and 7/51 (13.7%) for the placebo group (risk difference 0.8%, 95% confidence interval [CI] -12.1 to 13.7%; odds ratio [OR] 1.07, 95% CI 0.37-3.10). There was a greater odds of oocyte retrieval with growth hormone (OR 5.67, 95% CI 1.54-20.80) but no better chance of embryo transfer (OR 1.42, 95% CI 0.50-4.00). Birth weights were comparable. CONCLUSIONS Planned participant numbers were not reached. It was not possible to demonstrate an increase in live birth rate from the addition of growth hormone in women with a previous poor ovarian response to IVF.
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Affiliation(s)
- Robert J Norman
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia; , Fertility SA, 431 King William Road, Adelaide, SA 5000, Australia.
| | - Helen Alvino
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia
| | - Louise M Hull
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia
| | - Ben W Mol
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia; South Australian Health and Medical Research Institute, Robinson Research Institute, North Adelaide, SA 5006; Monash University, Clayton, VIC 3800, Australia
| | - Roger J Hart
- Fertility Specialists of Western Australia, Claremont, WA 6010; The University of Western Australia, Crawley, WA 6009, Australia
| | - Thu-Lan Kelly
- Adelaide Health Technology Assessment, School of Public Health, The University of Adelaide, Adelaide, SA 5006; Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, SA 5001, Australia
| | - Luk Rombauts
- Monash IVF, Monash Surgical Private Hospital, Clayton, VIC 3168, Australia
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Pericot-Valverde I, Secades-Villa R, Gutiérrez-Maldonado J. A randomized clinical trial of cue exposure treatment through virtual reality for smoking cessation. J Subst Abuse Treat 2019; 96:26-32. [DOI: 10.1016/j.jsat.2018.10.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 09/24/2018] [Accepted: 10/15/2018] [Indexed: 01/22/2023]
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Adib-Hajbaghery M, Nabizadeh-Gharghozar Z, Nasirpour P. Bias in clinical trials into the effects of complementary and alternative medicine therapies on hemodialysis patients. J Family Med Prim Care 2019; 8:2179-2183. [PMID: 31463227 PMCID: PMC6691419 DOI: 10.4103/jfmpc.jfmpc_186_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Chronic renal failure is among the major health challenges in the world. Many clinical trials have been conducted to assess the effects of complementary and alternative therapies on hemodialysis-related outcomes. However, a number of biases may affect the results of these studies. Aims: This study aimed to assess biases in randomized clinical trials into the effects of complementary and alternative therapies on hemodialysis patients. Settings and Design: A critical review on clinical trials into the effects of complementary and alternative therapies therapies on hemodialysis patients. Materials and Methods: This study was conducted on 114 randomized clinical trials which had been published in 2012–2017 into the effects of complementary and alternative therapies on hemodialysis patients. The Cochrane Risk of Bias Tool was employed to assess biases in the included trials. The collected data were presented using the measures of descriptive statistics, namely absolute and relative frequencies. Results: Among 114 included trials, 71.05% (81 trials) had used low bias methods for random sequence generation, while 60.52% (69 trials) had provided no clear information about allocation concealment. Moreover, respecting blinding, 57.89% of trials (66 trials) were low bias. Around 60.52% of trials (69 trials) had no attrition between randomization and final follow-up assessment and 84.21% (96 trials) had apparently reported all intended outcomes. Conclusions: This study shows that 50% of randomized clinical trials into the effects of complementary and alternative therapies on hemodialysis patients have low bias. Yet, quality improvement is still needed to produce more conclusive evidence.
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Affiliation(s)
- Mohsen Adib-Hajbaghery
- Department of Nursing, Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | | | - Parisa Nasirpour
- Department of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
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Gardiner MA, Wilkinson MH. Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma. J Pediatr 2019; 204:245-249.e2. [PMID: 30392872 DOI: 10.1016/j.jpeds.2018.08.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/03/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the efficacy of a breath-enhanced and a conventional jet nebulizer in the treatment of children with moderate to severe acute asthma. STUDY DESIGN We enrolled subjects between 6 and 18 years of age presenting to the emergency department (ED) with acute asthma and an initial forced expiratory volume in 1 second (FEV1) <70% of predicted. We excluded patients with chronic disease, who required immediate resuscitation, or failed spirometry. Subjects were randomized to breath-enhanced or conventional jet delivery of a 5-mg albuterol treatment. Our primary outcome was change in FEV1, and secondary outcomes included change in clinical asthma scores, ED length of stay, disposition, and side effects. Student t test and multivariable linear regression were used to evaluate the primary outcome. RESULTS In total, 497 patients were assessed for eligibility with 118 enrolled and 107 subjects available for analysis of the primary outcome. Improvement in FEV1 was significantly greater with conventional jet nebulizer (mean ΔFEV1 +13.8% vs +9.1%, P = .04). This difference remained significant after adjustment for baseline differences. Subgroup analysis of 57 subjects with spirometry meeting American Thoracic Society/European Respiratory Society guidelines yielded similar results (mean ΔFEV1 +14.5% vs +8.5%, P=.03). There were no significant differences in clinical asthma scores, ED length of stay, disposition, or side effects. CONCLUSIONS Albuterol delivered via conventional jet nebulizer resulted in significantly greater improvement in FEV1 than albuterol delivered by breath-enhanced nebulizer, without significant differences in clinical measures. Conventional jet nebulizers may deliver albuterol to children with acute asthma more effectively than breath-enhanced nebulizers. TRIAL REGISTRATION ClinicalTrials.gov: NCT02566902.
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Affiliation(s)
- Mike A Gardiner
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital-San Diego, La Jolla, CA.
| | - Matthew H Wilkinson
- Department of Pediatrics, University of Texas at Austin, Dell Children's Medical Center of Central Texas, Austin, TX
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Murray M, Dordevic AL, Cox KHM, Scholey A, Ryan L, Bonham MP. Study protocol for a double-blind randomised controlled trial investigating the impact of 12 weeks supplementation with a Fucus vesiculosus extract on cholesterol levels in adults with elevated fasting LDL cholesterol who are overweight or have obesity. BMJ Open 2018; 8:e022195. [PMID: 30552248 PMCID: PMC6303689 DOI: 10.1136/bmjopen-2018-022195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/29/2018] [Accepted: 10/09/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Hyperlipidaemia, hyperglycaemia and chronic inflammation are risk factors for chronic diseases cardiovascular disease and type 2 diabetes. Polyphenols are bioactive compounds found in marine algae with potential antihyperlipidaemic, antihyperglycaemic and anti-inflammatory effects. The modulation of these risk factors using bioactive polyphenols may represent a useful strategy for disease prevention and management; research in humans, however, remains limited. This trial aims to determine the impact of a polyphenol-rich brown seaweed extract on fasting hyperlipidaemia, hyperglycaemia and inflammation. Effects on mood and cognition will also be evaluated. METHODS AND ANALYSIS Fifty-eight hypercholesterolaemic participants who are overweight or have obesity will be randomised to receive either a polyphenol-rich brown seaweed extract (2000 mg dose containing 600 mg polyphenols) or placebo (2000 mg rice flour) daily for 12 weeks. Fasting venous blood samples will be taken at baseline, week 6 and week 12 of the intervention to assess serum cholesterol (total, low-density lipoprotein and high-density lipoprotein) and triglyceride concentrations, plasma glucose and insulin concentrations and markers of inflammation. Mood and cognitive function will be evaluated as exploratory outcomes. Independent t-tests or equivalent will be used to determine differences between the two groups in changes from baseline to week 12. Analysis of variance will be used to assess differences between the groups across the three time points (baseline, week 6 and week 12). ETHICS AND DISSEMINATION Ethics approval has been granted by the Monash University Human Research Ethics Committee (2017-8689-10379). Results from this trial will be disseminated through publication in peer-reviewed journals, national and international presentations, and a PhD thesis. These results are essential to inform the use of polyphenol-rich brown seaweeds as a functional food or nutritional supplement ingredients for health promotion and disease prevention and management in humans. TRIAL REGISTRATION NUMBER ACTRN12617001039370; Pre-results.
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Affiliation(s)
- Margaret Murray
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia
| | - Aimee L Dordevic
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia
| | - Katherine H M Cox
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Andrew Scholey
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Lisa Ryan
- Department of Natural Sciences, Galway-Mayo Institute of Technology, Galway, Ireland
| | - Maxine P Bonham
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia
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Yelland LN, Kahan BC, Dent E, Lee KJ, Voysey M, Forbes AB, Cook JA. Prevalence and reporting of recruitment, randomisation and treatment errors in clinical trials: A systematic review. Clin Trials 2018; 15:278-285. [PMID: 29638145 DOI: 10.1177/1740774518761627] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation or treatment errors was found in the remaining 50 of 82 trials (61%). Based on responses from 9 of the 15 corresponding authors who were contacted regarding recruitment, randomisation and treatment errors, between 1% and 100% of the errors that occurred in their trials were reported in the trial publications. Conclusion Recruitment, randomisation and treatment errors are common in individually randomised, phase III trials published in leading medical journals, but reporting practices are inadequate and reporting standards are needed. We recommend researchers report all such errors that occurred during the trial and describe how they were handled in trial publications to improve transparency in reporting of clinical trials.
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Affiliation(s)
- Lisa N Yelland
- 1 South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,2 School of Public Health, The University of Adelaide, Adelaide, SA, Australia
| | - Brennan C Kahan
- 3 Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Elsa Dent
- 4 Centre for Research in Geriatric Medicine, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Katherine J Lee
- 5 Clinical Epidemiology and Biostatistics Unit and Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Parkville, VIC, Australia.,6 Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Merryn Voysey
- 7 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew B Forbes
- 8 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jonathan A Cook
- 9 Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,10 Surgical Intervention Trials Unit, University of Oxford, Oxford, UK
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Streimann K, Trummal A, Klandorf K, Akkermann K, Sisask M, Toros K, Selart A. Effectiveness of a universal classroom-based preventive intervention (PAX GBG): A research protocol for a matched-pair cluster-randomized controlled trial. Contemp Clin Trials Commun 2017; 8:75-84. [PMID: 29696198 PMCID: PMC5898545 DOI: 10.1016/j.conctc.2017.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/17/2017] [Accepted: 08/26/2017] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The PAX Good Behavior Game (PAX GBG) is a universal classroom-based program that promotes children's mental health. In Estonia, the intervention is delivered to first grade students (aged seven to eight) within the regular school curriculum. The current work describes a protocol for a cluster-randomized controlled trial (RCT) of the PAX GBG conducted in Estonia. DESIGN AND METHODS This is an ongoing, pragmatic, two-year, matched-pair, cluster-RCT conducted in Estonian elementary schools. Schools were matched to pairs based on their geographical location and number of students per classroom. One school in each pair was randomly selected to receive the intervention and the other placed on a wait-list as a control. 42 schools provided baseline data during the autumn of 2016. Data is collected at two more points in time - seven months and 19 months post-baseline. Outcomes of children's mental health and behavior are measured by the teacher- and parent-rated Strengths and Difficulties Questionnaire, parent-rated Swanson, Nolan, and Pelham - IV Questionnaire and the Go/No-Go task completed by children. Teachers also rate their self-efficacy and overall classroom behavior. DISCUSSION This study aims to test the effectiveness of the intervention in Estonian classrooms with a newer version of the rigorously tested GBG program. To our knowledge, this study is the first to measure the effects of the intervention on children's inhibitory control, which has been associated with externalizing problems in the literature. The results from this trial will provide further understanding into how the program influences children's well-being and self-control. TRIAL REGISTRATION ClinicalTrials.gov registry (NCT02865603).
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Affiliation(s)
- Karin Streimann
- National Institute for Health Development, Tallinn, Estonia
- School of Governance, Law and Society, Tallinn University, Tallinn, Estonia
| | - Aire Trummal
- National Institute for Health Development, Tallinn, Estonia
| | - Kai Klandorf
- National Institute for Health Development, Tallinn, Estonia
| | - Kirsti Akkermann
- Institute of Psychology, University of Tartu, Tartu, Estonia
- Center for Cognitive Behavior Therapy, Tartu, Estonia
| | - Merike Sisask
- School of Governance, Law and Society, Tallinn University, Tallinn, Estonia
- Estonian-Swedish Mental Health and Suicidology Institute, Tallinn, Estonia
| | - Karmen Toros
- School of Governance, Law and Society, Tallinn University, Tallinn, Estonia
| | - Anne Selart
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
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Cazzell S, Vayser D, Pham H, Walters J, Reyzelman A, Samsell B, Dorsch K, Moore M. A randomized clinical trial of a human acellular dermal matrix demonstrated superior healing rates for chronic diabetic foot ulcers over conventional care and an active acellular dermal matrix comparator. Wound Repair Regen 2017; 25:483-497. [PMID: 28544150 DOI: 10.1111/wrr.12551] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 05/09/2017] [Indexed: 02/03/2023]
Abstract
This study compared the efficacy and safety of a human acellular dermal matrix (ADM), D-ADM, with a conventional care arm and an active comparator human ADM arm, GJ-ADM, for the treatment of chronic diabetic foot ulcers. The study design was a prospective, randomized controlled trial that enrolled 168 diabetic foot ulcer subjects in 13 centers across 9 states. Subjects in the ADM arms received one application but could receive one additional application of ADM if deemed necessary. Screen failures and early withdrawals left 53 subjects in the D-ADM arm, 56 in the conventional care arm, and 23 in the GJ-ADM arm (2:2:1 ratio). Subjects were followed through 24 weeks with major endpoints at Weeks 12, 16, and 24. Single application D-ADM subjects showed significantly greater wound closure rates than conventional care at all three endpoints while all applications D-ADM displayed a significantly higher healing rate than conventional care at Week 16 and Week 24. GJ-ADM did not show a significantly greater healing rate over conventional care at any of these time points. A blinded, third party adjudicator analyzed healing at Week 12 and expressed "strong" agreement (κ = 0.837). Closed ulcers in the single application D-ADM arm remained healed at a significantly greater rate than the conventional care arm at 4 weeks posttermination (100% vs. 86.7%; p = 0.0435). There was no significant difference between GJ-ADM and conventional care for healed wounds remaining closed. Single application D-ADM demonstrated significantly greater average percent wound area reduction than conventional care for Weeks 2-24 while single application GJ-ADM showed significantly greater wound area reduction over conventional care for Weeks 4-6, 9, and 11-12. D-ADM demonstrated significantly greater wound healing, larger wound area reduction, and a better capability of keeping healed wounds closed than conventional care in the treatment of chronic DFUs.
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Affiliation(s)
- Shawn Cazzell
- Limb Preservation Platform, Valley Vascular Surgical Associates, Fresno, California
| | | | - Hau Pham
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Jodi Walters
- Southern Arizona VA Health Care System, Tucson, Arizona
| | - Alexander Reyzelman
- UCSF Center for Limb Preservation, California School of Podiatric Medicine at Samuel Merritt University, San Francisco, California
| | | | | | - Mark Moore
- LifeNet Health, Virginia Beach, Virginia
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Intention-to-treat Analysis Controls the Bias When Suffer From Noncompliance and Missing Outcomes in Randomized Controlled Trial Study. Ann Surg 2016; 266:e78-e79. [PMID: 27049767 DOI: 10.1097/sla.0000000000001728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gleicher N, Kushnir VA, Barad DH. The impact of patient preselection on reported IVF outcomes. J Assist Reprod Genet 2016; 33:455-9. [PMID: 26861966 DOI: 10.1007/s10815-016-0673-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/26/2016] [Indexed: 10/22/2022] Open
Abstract
We, in this manuscript, address the fact that increasing numbers of published studies in reproductive medicine selectively report outcomes for only favorably selected patients; while failing to note that, so reported outcome data,therefore, cannot be applied to unselected patient populations. Almost all favorable patient selection methods, starting with prolonged embryo culture to blastocyst stage, have, thus, been widely misrepresented in the literature since they almost universally report outcomes only in reference to embryo transfer. These outcome reports, however, do not include outcomes for poorer prognosis patients who do not reach embryo transfer. Study outcomes are universally applicable only if performed in unselected patient populations and reported with reference point cycle start (intent to treat). All other studies greatly exaggerate clinical pregnancy and live birth rates if applied to general populations, unless specifically noting that they can be extrapolated only to women who reach embryo transfer.
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Affiliation(s)
- Norbert Gleicher
- The Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA. .,The Foundation for Reproductive Medicine, New York, NY, USA. .,The Rockefeller University, New York, NY, USA.
| | - Vitaly A Kushnir
- The Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA.,Department of Obstetrics and Gynecology, Wake Forest University, Winston Salem, NC, USA
| | - David H Barad
- The Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA.,The Foundation for Reproductive Medicine, New York, NY, USA
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Kahan BC, Forbes AB, Doré CJ, Morris TP. A re-randomisation design for clinical trials. BMC Med Res Methodol 2015; 15:96. [PMID: 26541982 PMCID: PMC4634916 DOI: 10.1186/s12874-015-0082-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 10/07/2015] [Indexed: 11/17/2022] Open
Abstract
Background Recruitment to clinical trials is often problematic, with many trials failing to recruit to their target sample size. As a result, patient care may be based on suboptimal evidence from underpowered trials or non-randomised studies. Methods For many conditions patients will require treatment on several occasions, for example, to treat symptoms of an underlying chronic condition (such as migraines, where treatment is required each time a new episode occurs), or until they achieve treatment success (such as fertility, where patients undergo treatment on multiple occasions until they become pregnant). We describe a re-randomisation design for these scenarios, which allows each patient to be independently randomised on multiple occasions. We discuss the circumstances in which this design can be used. Results The re-randomisation design will give asymptotically unbiased estimates of treatment effect and correct type I error rates under the following conditions: (a) patients are only re-randomised after the follow-up period from their previous randomisation is complete; (b) randomisations for the same patient are performed independently; and (c) the treatment effect is constant across all randomisations. Provided the analysis accounts for correlation between observations from the same patient, this design will typically have higher power than a parallel group trial with an equivalent number of observations. Conclusions If used appropriately, the re-randomisation design can increase the recruitment rate for clinical trials while still providing an unbiased estimate of treatment effect and correct type I error rates. In many situations, it can increase the power compared to a parallel group design with an equivalent number of observations. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0082-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, E1 2AB, UK.
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia.
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, WC1E 6BT, UK.
| | - Tim P Morris
- Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, London, WC2B 6NH, UK.
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