CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials. 2010;11:32. [PMID: 20334632 PMCID: PMC2857832 DOI: 10.1186/1745-6215-11-32]

Effectiveness and cost-effectiveness of online recorded recovery narratives in improving quality of life for people with psychosis experience (NEON Trial): a pragmatic randomised controlled trial

Background

The Narrative Experiences Online (NEON) Intervention provides self-managed web-based access to mental health recovery narratives (n = 659). We evaluated effectiveness and cost-effectiveness in improving quality of life for adults resident in England with mental health problems and recent psychosis experience.

Methods

Prospectively registered pragmatic parallel-group randomised trial controlling for usual care, recruiting from statutory mental health services and through community engagement activities, with a 52-week primary endpoint (ISRCTN11152837). All trial procedures and the NEON Intervention were delivered by an integrated web-application. Randomisation was through an independently generated list (no stratification). Allocation was masked for statistical staff and the Chief Investigator but not participants. Intervention arm participants received immediate NEON Intervention access. Control arm participants received access after completing primary endpoint questionnaires. The primary outcome was quality of life through the Manchester Short Assessment (MANSA). Serious Adverse Events (SAEs) were collected through web-based safety report forms and identified from health service usage data. The primary analysis was by a prospectively described Intention To Treat principle excluding participants who had registered multiple times, with multiple imputation for missing data.

Findings

Between 9 March 2020 and 1 March 2021, 739 participants were randomised (intervention:370; control: 369), providing more than 90% power to detect a baseline-adjusted difference of 0.25 in the MANSA score. Mean age was 34.8 years (standard deviation (SD) 12.0), 561 (75.9%) were white British, 443 (59.9%) were female, 609 (82.4%) had accessed specialist care mental health services, and 698 (94.5%) had accessed primary care mental health services. Mean baseline MANSA score was 3.7 for control and intervention arms (SD 0.9 and 1.0). 565 (76.5%) participants provided primary endpoint MANSA data with a mean score of 4.1 (SD 1.0) for both arms. We found no significant difference in Quality of Life between the two arms at the primary endpoint (baseline-adjusted difference 0.07, 95% CI -0.07 to 0.21, p = 0.35). The incremental cost-effectiveness ratio (£110,501 per quality-adjusted life-year (QALY)) exceeded the prospectively defined cost-effectiveness threshold (£30,000 per QALY). 158 (42.8%) control arm and 194 (52.4%) intervention arm participants accessed narratives outside of the NEON Intervention. There were no related serious adverse events (SAEs). 116 unrelated SAEs were reported by control arm participants, and 107 by intervention arm participants.

Interpretation

Our findings do not indicate NEON Intervention access for all people with psychosis experience. Future research should consider a) evaluation with current mental health services users; b) optimisation to enable users to find hope-promoting narratives.

Funding

National Institute for Health and Care Research (NIHR).

Surgical intervention combined with weight-bearing walking training promotes recovery in patients with chronic spinal cord injury: a randomized controlled study

JOURNAL/nrgr/04.03/01300535-202412000-00032/figure1/v/2024-04-08T165401Z/r/image-tiff For patients with chronic spinal cord injury, the conventional treatment is rehabilitation and treatment of spinal cord injury complications such as urinary tract infection, pressure sores, osteoporosis, and deep vein thrombosis. Surgery is rarely performed on spinal cord injury in the chronic phase, and few treatments have been proven effective in chronic spinal cord injury patients. Development of effective therapies for chronic spinal cord injury patients is needed. We conducted a randomized controlled clinical trial in patients with chronic complete thoracic spinal cord injury to compare intensive rehabilitation (weight-bearing walking training) alone with surgical intervention plus intensive rehabilitation. This clinical trial was registered at ClinicalTrials.gov (NCT02663310). The goal of surgical intervention was spinal cord detethering, restoration of cerebrospinal fluid flow, and elimination of residual spinal cord compression. We found that surgical intervention plus weight-bearing walking training was associated with a higher incidence of American Spinal Injury Association Impairment Scale improvement, reduced spasticity, and more rapid bowel and bladder functional recovery than weight-bearing walking training alone. Overall, the surgical procedures and intensive rehabilitation were safe. American Spinal Injury Association Impairment Scale improvement was more common in T7-T11 injuries than in T2-T6 injuries. Surgery combined with rehabilitation appears to have a role in treatment of chronic spinal cord injury patients.

Aquatic High-Intensity Interval Deep Water Running Influence on Cardiometabolic Health and Cognitive Psychological Responses in Women

PURPOSE

To investigate the effects of an 8-wk AHIIT-DWR intervention compared with land-based HIT training (LHIIT) on cardiometabolic health, cognitive, and psychological outcomes in inactive elderly women.

METHODS

Seventy inactive elderly women aged 60 yr or above were randomly assigned into two groups: AHIIT-DWR and LHIIT. The AHIIT-DWR group engaged in DWR sessions comprising 30 min of interval training, consisting of ten 2-min exercise bouts at 80%-90% of their maximal heart rate (HR max ), with 1-min active recovery at 70% HR max between bouts, for two sessions per week, for 8 wk. The LHIIT group performed treadmill running at the same intensity.

RESULTS

Both groups showed similar cardiovascular fitness, maximal aerobic capacity (V̇O 2max ), HR max , and RER improvement ( P > 0.05), whereas AHIIT-DWR showed a significant improvement in aerobic capacity minute ventilation (V̇E), metabolic equivalents (METs), and O 2 pulse ( P < 0.05) over the 8-wk intervention. Both AHIIT-DWR and LHIIT significantly decreased triglycerides, total cholesterol, HDL, and LDL postintervention ( P < 0.05). No significant group differences were observed for cognitive function assessed by MMSE and MOCA ( P > 0.05). Both groups showed similar enjoyment levels, self-efficacy scores, and high adherence rates (>90%).

CONCLUSIONS

Our study suggests that AHIIT-DWR can elicit a similar improvement in cardiorespiratory health, metabolic blood markers, cognitive function assessed by MMSE and MOCA, and psychological responses as LHIIT in inactive elderly women.

Is severe carbohydrate restriction necessary for appetite suppression? The ASKED randomized controlled trial

OBJECTIVE

This trial aimed to compare three low-energy diets (LEDs) with different amounts of carbohydrates (CHO) on ketosis and changes in hunger feelings in adults with obesity.

METHODS

A total of 101 adults (51 female) with obesity (BMI, mean [SEM], 34.7 [0.4] kg/m2) were randomized to follow three isocaloric LEDs (1000 kcal/day) for 8 weeks, containing either low, medium, or high CHO (70, 100, and 130 g/day, respectively), and 4 weeks of refeeding and weight stabilization. Body weight (BW) and composition, hunger and other appetite ratings, concentrations of β-hydroxybutyrate (βHB), and appetite-related hormones were measured at baseline and at the end of weeks 8 and 12.

RESULTS

At week 8, weight loss and βHB concentrations were significantly different among groups: Low CHO group versus Medium CHO group (BW: 2.32 [0.95] kg, 95% CI: 0.44 to 4.21, p = 0.016; βHB: -0.40 [0.09] mM, 95% CI: -0.67 to -0.09, p < 0.001); Low CHO group versus High CHO group (BW: 2.29 [0.96] kg, 95% CI: 0.39 to 4.19, p = 0.016; βHB: -0.644 [0.10] mM, 95% CI: -0.84 to -0.44, p < 0.001); and Medium CHO group versus High CHO group (BW: -0.03 [0.94] kg, 95% CI: -1.89 to 1.84, p = 0.977; βHB: -0.15 [0.08] mM, 95% CI: -0.30 to 0.002, p = 0.054). No significant differences in hunger were found among groups: Low CHO group versus Medium CHO group (-10.87 [5.92] mm, 95% CI: -0.82 to 22.57, p = 0.068); Low CHO group versus Medium CHO group (7.74 [7.36] mm, 95% CI: -6.77 to 22.26, p = 0.294); and Medium CHO group versus High CHO group (-3.13 [7.48] mm, 95% CI: -17.89 to 11.63, p = 0.676).

CONCLUSIONS

Although the findings of this trial are not definitive, changes in hunger ratings with weight loss did not differ among groups. Additional studies with CHO intake of up to 130 g in 1000-kcal/day LEDs are warranted to replicate these findings.

Pre-oxygenation using high flow humidified nasal oxygen or face mask oxygen in pregnant people - a prospective randomised controlled crossover non-inferiority study (The HINOP2 study)

BACKGROUND

Airway guidelines recommend pre-oxygenation of obstetric patients to an end tidal oxygen concentration (etO2) ≥90%. High flow nasal oxygen (HFNO) achieves this in 60% of pregnant people. However face mask (FM) pre-oxygenation also may not achieve this target in all patients. In this study we determined whether HFNO pre-oxygenation is non-inferior to FM pre-oxygenation.

METHODS

This randomised controlled crossover non-inferiority trial was conducted on healthy participants of gestational age ≥37 weeks in a simulated environment. Participants underwent pre-oxygenation for three minutes with HFNO and FM oxygen in randomised order. HFNO was delivered at a maximal flow of 70 l.min-1 and FM oxygen at 10 l.min-1. The primary outcome was etO2 on first expired breath after pre-oxygenation. Non-inferiority was defined as a mean difference in first etO2 between groups of ≤5%.

RESULTS

Seventy participants were randomised with 62 analysed. Age (mean (SD)), gestation (median (IQR)), and body mass index (median (IQR)), were 34.7 (4.6) years, 39 (38.4, 39.4) weeks, 29 (26.6, 32.4) kg.m-2 respectively. First etO2 after HFNO pre-oxygenation was greater than after FM pre-oxygenation (HFNO pre-oxygenation mean (SD) 90.2 (3.9)% versus FM pre-oxygenation 88.7 (3.0)%; mean difference = 1.45%, 95% CI 0.19 to 2.72%; p = 0.025. Forty-four (71%) participants achieved ≥90% first etO2 concentration after HFNO pre-oxygenation versus 27 (44%) after FM pre-oxygenation (p = 0.002).

CONCLUSIONS

In this cohort of pregnant people at term in a simulated environment, pre-oxygenation with HFNO was not inferior to FM pre-oxygenation. FM pre-oxygenation did not achieve pre-oxygenation targets in over 50% of participants.

Collagenase Injection versus Limited Fasciectomy for Dupuytren's Contracture

BACKGROUND

Treatments for Dupuytren's contracture include limited fasciectomy and collagenase injection. Comparisons of the effectiveness of these treatments have been limited.

METHODS

We performed an unblinded, multicenter, pragmatic, two-group, randomized, controlled noninferiority trial comparing collagenase injection with limited fasciectomy in persons with moderate Dupuytren's contracture. The primary outcome was the score on the Patient Evaluation Measure-Hand Health Profile (PEM), a questionnaire for assessing hand health as reported by the patient, at 1 year after treatment. Scores on the PEM range from 0 to 100, with higher scores indicating worse outcomes. The prespecified noninferiority margin was 6 points.

RESULTS

A total of 672 persons (336 per group) were assigned to receive collagenase injection or to undergo limited fasciectomy. The primary analysis included 599 persons: 314 in the collagenase group and 285 in the limited-fasciectomy group. The mean score on the PEM at 1 year was 17.8 among the 284 patients with available data in the collagenase group and 11.9 among the 250 patients with available data in the limited-fasciectomy group (estimated difference, 5.9 points; 95% confidence interval [CI], 3.1 to 8.8; one-sided P = 0.49 for noninferiority). Among the patients with available data (229 patients in the collagenase group and 197 patients in the limited-fasciectomy group), the estimated difference in the mean score on the PEM at 2 years was 7.2 points (95% CI, 4.2 to 10.9). Moderate or severe complications of treatment occurred in 1.8% of the patients in the collagenase group and in 5.1% of those in the limited-fasciectomy group; recurrent contracture resulted in reintervention in 14.6% and 3.4%, respectively.

CONCLUSIONS

Collagenase injection was not noninferior to limited fasciectomy with respect to the score on the PEM at 1 year after treatment. (Funded by the National Institute for Health and Care Research Health Technology Assessment Programme; DISC ISRCTN Registry number ISRCTN18254597.).

Application of human-centered design principles to wearable exoskeletons: a systematic review

Purpose of the article: As technologies continue to advance, designing wearable exoskeletons that are comfortable, safe, reliable, and engaging for users is an arduous task. The integration of HCD principles in exoskeleton development significantly contributes to ensuring that the product meets the needs and preferences of users. This study systematically reviews the application of human-centred design (HCD) principles in the development of wearable exoskeletons.

Methodology: It synthesizes existing literature, identifies key HCD concepts and assesses their impact on exoskeleton usability, comfort, and safety. The findings of the study revealed a moderate application of HCD in many of the studies; however, the concepts were found to play a crucial role in enhancing the usability, safety, and comfort of wearable exoskeleton technology implementation. Challenges revealed in the study include limited stakeholder involvement, a lack of standardized evaluation metrics, non-consideration of ethical, legal, and social issues, and a lack of studies on the potential adverse effects of exoskeleton use. Besides identifying the challenges faced in integrating HCD principles into exoskeleton development, the study also proposed pragmatic approaches to overcome them.

Results: The study underscores the significance of incorporating human-centred design principles in the design and development of wearable exoskeletons. This has implications for industry, rehabilitation, health, and agriculture to churn out positive outcomes. The research contributes to the expanding literature on wearable exoskeletons and HCD, offering valuable insights into the advancement of this technology in various domains and suggesting areas for future studies to address identified gaps.

Short-term results of unroofing and marsupialization compared to the Karydakis technique in the treatment of pilonidal sinus. A randomized prospective study

INTRODUCTION

The treatment of pilonidal sinus (PS) is usually surgical, but no procedure is considered the gold standard. The Karydakis (K) technique is widely used, and unroofing and marsupialization (UM) is a simple surgery with good results.

PRIMARY OBJECTIVE

To evaluate early postoperative complications (EPC) 30 days after UM surgery compared to the K technique.

SECONDARY OBJECTIVES

To evaluate surgical time, postoperative pain, patient satisfaction, return to daily activity and early recurrence within 3 months.

METHOD

Prospective, single-center, randomized study in patients who underwent surgery for primary PS with no abscess between June 2016 and November 2017. They were randomized using a computer-generated block method. To analyze the main objective, a non-inferiority analysis was performed.

RESULTS

122 patients with symptomatic primary PS were randomized: 60 in the K group and 62 in the UM group. Both groups were homogeneous. There were statistically significant differences between surgery and postoperative complications at 15 and 30 days in favor of UM. There were also differences in favor of UM in surgical time and return to daily activity. During the 90-day follow-up, there were 3 recurrences in the UM group and 0 in the K group.

CONCLUSIONS

UM is a simple, minimally invasive, easily reproducible technique that has a lower rate of early complications, with a shorter operative time and an earlier return to daily activity.

Fluid balance neutralization secured by hemodynamic monitoring versus protocolized standard of care in patients with acute circulatory failure requiring continuous renal replacement therapy: results of the GO NEUTRAL randomized controlled trial

PURPOSE

Net ultrafiltration (UFNET) during continuous renal replacement therapy (CRRT) can control fluid balance (FB), but is usually 0 ml·h-1 in patients with vasopressors due to the risk of hemodynamic instability associated with CRRT (HIRRT). We evaluated a UFNET strategy adjusted by functional hemodynamics to control the FB of patients with vasopressors, compared to the standard of care.

METHODS

In this randomized, controlled, open-label, parallel-group, multicenter, proof-of-concept trial, adults receiving vasopressors, CRRT since ≤ 24 h and cardiac output monitoring were randomized (ratio 1:1) to receive during 72 h a UFNET ≥ 100 ml·h-1, adjusted using a functional hemodynamic protocol (intervention), or a UFNET ≤ 25 ml·h-1 (control). The primary outcome was the cumulative FB at 72 h and was analyzed in patients alive at 72 h and in whom monitoring and CRRT were continuously provided (modified intention-to-treat population [mITT]). Secondary outcomes were analyzed in the intention-to-treat (ITT) population.

RESULTS

Between June 2021 and April 2023, 55 patients (age 69 [interquartile range, IQR: 62; 74], 35% female, Sequential Organ Failure Assessment (SOFA) 13 [11; 15]) were randomized (25 interventions, 30 controls). In the mITT population, (21 interventions, 24 controls), the 72 h FB was -2650 [-4574; -309] ml in the intervention arm, and 1841 [821; 5327] ml in controls (difference: 4942 [95% confidence interval: 2736-6902] ml, P < 0.01). Hemodynamics, oxygenation and the number of HIRRT at 72 h, and day-90 mortality did not statistically differ between arms.

CONCLUSION

In patients with vasopressors, a UFNET fluid removal strategy secured by a hemodynamic protocol allowed active fluid balance control, compared to the standard of care.

The effectiveness and cost-effectiveness of attachment-based family therapy for young adults with high suicidal ideation: protocol of a randomized controlled trial

BACKGROUND

Young adult suicidality is worldwide a prevalent mental health problem and the number one cause of death, with devastating consequences for individuals and their families, and substantial economic costs. However, psychological and pharmacological treatments currently recommended in guidelines for treatment of high-risk youth for fatal suicide have limited effect. In line with the World Health Organization's (WHO) recommendation to involve the family in treatment of these youth, attachment-based family therapy (ABFT) was developed, a 16-week attachment and emotion-focused treatment, implemented in mental health care settings across various European countries in the past years, and becoming increasingly popular among therapists. However, the (cost-)effectiveness of ABFT has not been studied in emerging adults. In the proposed pragmatic randomized controlled trial (RCT), we aim to evaluate the effectiveness and cost-effectiveness of ABFT compared to treatment as usual (TAU) on suicidality, as delivered in daily practice.

METHODS

This pragmatic multicenter study in the Netherlands and Belgium includes 13 participating sites. Participants are suicidal young adults (≥ 31 SIQ-JR score) between 16 and 30 years old who seek mental health treatment (n = 142) and their caregivers. The primary outcome is suicidality (SIQ-JR), with assessments at baseline, post-intervention (5 months after baseline), 3, 6, and 12 months after intervention. We predict that, compared to TAU, ABFT will lead to a stronger reduction in suicidality and will be more cost-effective, over the course of all time points. We also expect stronger decreases in depressive symptoms, given that suicidality is very common in individuals with depressive disorder, as well as more improvement in family functioning, autonomy, entrapment, and young adult attachment, in the ABFT condition.

DISCUSSION

This study can contribute to improving the care for suicidal youngsters with high mortality risk. Treatment of suicidal emerging adults is understudied. The results will inform clinical guidelines and policy makers and improve treatment of suicidal emerging adults.

TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov (NCT05965622, first posted on July 28, 2023).

Rescue analgesia with a transversus abdominis plane block alleviates moderate-to-severe pain and improves oxygenation after abdominal surgery: a randomized controlled trial

Background

Abdominal surgery is a common surgical procedure that is frequently associated with substantial postoperative pain. However, rescue analgesia using opioids is associated with several adverse effects. The transversus abdominis plane block (TAPB) has been demonstrated to be effective as part of multimodal analgesia. This study aims to evaluate the effects of rescue analgesia using the TAPB following abdominal surgery.

Methods

Ninety patients undergoing abdominal surgery and reporting a numeric rating scale (NRS) score of cough pain ≥4 on the first postoperative day were randomized to receive either sufentanil or TAPB for rescue analgesia. Pain scores and arterial oxygen pressure (PaO2) were evaluated before and after the administration of rescue analgesia. Sleep quality and gastrointestinal function were assessed postoperatively. The primary outcome was the degree of pain relief on coughing 30 min after the administration of rescue analgesia.

Results

Patients of both groups reported a significantly reduced NRS score on coughing 30 min after receiving rescue analgesia (P paired < 0.001 for both groups). Notably, the degree of pain relief was significantly higher in the TAPB group than in the sufentanil group [median (interquartile range), -3 (-4 to -2) vs. -2 (-2 to -1), median difference = -1; 95% confidence interval, -2 to -1; P < 0.001]. Moreover, patients in the TAPB group experienced less pain than those in the sufentanil group during the following 24 h. When evaluated, PaO2 increased significantly after rescue analgesia was administered in the TAPB group (P paired < 0.001); however, there were no significant intragroup differences in the sufentanil group (P paired = 0.129). Patients receiving the TAPB experienced better quality of sleep than those receiving sufentanil (P = 0.008), while no statistical differences in gastrointestinal function were observed between the two groups.

Conclusion

Rescue analgesia with the TAPB on the first postoperative day alleviated pain, enhanced oxygenation, and improved sleep quality in patients undergoing abdominal surgery; however, its effect on gastrointestinal function requires further research.

Clinical Trial Registration

This study was registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/showproj.html?proj=170983, ChiCTR2200060285) on 26 May 2022: Patients were recruited during the period between 30 May 2022 and 14 February 2023, and a follow-up of the last enrolled patient was completed on 16 March 2023.

Short-term efficacy of moderate-intensity rosuvastatin in coronavirus disease 2019 patients: A randomized clinical trial

As the coronavirus disease 2019 (COVID-19) pandemic persists, the exploration of adjunct therapies to mitigate disease severity remains a priority. Statins, known for their pleiotropic effects, have been under investigation for their potential role in managing COVID-19 complications. The study was conducted in a single referral hospital and adhered to Consolidated Standards of Reporting Trials guidelines. Eligible participants were randomized in a 1:1 ratio into either the rosuvastatin group or the control group. Outcome measures included vital signs, laboratory data, clinical outcomes, and patient symptoms. Statistical analysis was performed using SPSS software (version 26.0, IBM Corp., Armonk, New York). A total of 100 patients were enrolled. No significant differences were observed between the rosuvastatin and control groups in terms of baseline characteristics and laboratory parameters, except for the fact that rosuvastatin-treated patients showed lower levels of C-reactive protein in comparison with the controls on both the 1st and 5th days (38.1 ± 16.3 vs 50.5 ± 25.3) compared to the control group. Clinical outcomes, including hospital length of stay, intensive care unit admission, need for intubation, and 1-month mortality, did not differ significantly between the two groups. Symptom scales, as assessed by the Borg Rating of Perceived Exertion and Leicester Cough Questionnaire, showed significant improvement in the rosuvastatin group compared to controls. Our study provides insights into the short-term efficacy of moderate-intensity rosuvastatin in COVID-19 patients. Further research is warranted to elucidate the long-term effects and optimal dosing of statins in COVID-19 management.

Wire-in-needle versus conventional syringe-on-needle technique for ultrasound-guided central venous catheter insertion in the internal jugular vein: the WIN randomized trial

PURPOSE

There are different techniques for ultrasound-guided central venous catheter (CVC) insertion. When using the conventional syringe-on-needle technique, the syringe needs to be removed from the needle after venous puncture to pass the guidewire through the needle into the vein. When, alternatively, using the wire-in-needle technique, the needle is preloaded with the guidewire, and the guidewire-after venous puncture-is advanced into the vein under real-time ultrasound guidance. We tested the hypothesis that the wire-in-needle technique reduces the time to successful guidewire insertion in the internal jugular vein compared with the syringe-on-needle technique in adults.

METHODS

We randomized 250 patients to the wire-in-needle or syringe-on-needle technique. Our primary endpoint was the time to successful guidewire insertion in the internal jugular vein.

RESULTS

Two hundred and thirty eight patients were analyzed. The median (25th percentile, 75th percentile) time to successful guidewire insertion was 22 (16, 38) s in patients assigned to the wire-in-needle technique and 25 (19, 34) s in patients assigned to the syringe-on-needle technique (estimated location shift: 2 s; 95%-confidence-interval: - 1 to 5 s, p = 0.165). CVC insertion was successful on the first attempt in 103/116 patients (89%) assigned to the wire-in-needle technique and in 113/122 patients (93%) assigned to the syringe-on-needle technique. CVC insertion-related complications occurred in 8/116 patients (7%) assigned to the wire-in-needle technique and 19/122 patients (16%) assigned to the syringe-on-needle technique.

CONCLUSION

The wire-in-needle technique-compared with the syringe-on-needle technique-did not reduce the time to successful guidewire insertion in the internal jugular vein. Clinicians can consider either technique for ultrasound-guided CVC insertion in adults.

Time to Sustained Recovery Among Outpatients With COVID-19 Receiving Montelukast vs Placebo: The ACTIV-6 Randomized Clinical Trial

Importance

The effect of montelukast in reducing symptom duration among outpatients with mild to moderate COVID-19 is uncertain.

Objective

To assess the effectiveness of montelukast compared with placebo in treating outpatients with mild to moderate COVID-19.

Design, Setting, and Participants

This randomized clinical trial (Accelerating COVID-19 Therapeutic Interventions and Vaccines [ACTIV]-6) was conducted from January 27 through June 23, 2023, during the circulation of Omicron subvariants. Participants aged 30 years or older with confirmed SARS-CoV-2 infection and 2 or more acute COVID-19 symptoms for less than 7 days were included across 104 US sites.

Interventions

Participants were randomized 1:1 to receive montelukast, 10 mg once daily, or matched placebo for 14 days.

Main Outcomes and Measures

The primary outcome was time to sustained recovery (defined as ≥3 consecutive days without symptoms). Secondary outcomes included time to death; time to hospitalization or death; a composite of health care utilization events (hospitalization, urgent care clinic visit, emergency department visit, or death); COVID-19 clinical progression scale score; and difference in mean time unwell. A modified intention-to-treat approach was used for the analysis.

Results

Among 1250 participants who were randomized and received the study drug or placebo, the median age was 53 years (IQR, 42-62 years), 753 (60.2%) were female, and 704 (56.3%) reported receiving 2 or more doses of a SARS-CoV-2 vaccine. Among 628 participants who received montelukast and 622 who received placebo, differences in time to sustained recovery were not observed (adjusted hazard ratio [AHR], 1.02; 95% credible interval [CrI], 0.92-1.12; P = .63 for efficacy). Unadjusted median time to sustained recovery was 10 days (95% CI, 10-11 days) in both groups. No deaths occurred, and hospitalizations were reported for 2 participants (0.3%) in each group; the composite of health care utilization events was reported for 18 participants (2.9%) in the montelukast group and 18 (2.9%) in the placebo group (AHR, 1.01; 95% CrI, 0.45-1.84; P = .48 for efficacy). Five participants (0.4%) experienced serious adverse events (3 [0.5%] in the montelukast group and 2 [0.3%] in the placebo group).

Conclusions and Relevance

In this randomized clinical trial of outpatients with mild to moderate COVID-19, treatment with montelukast did not reduce duration of COVID-19 symptoms. These findings do not support the use of montelukast for the treatment of mild to moderate COVID-19.

Trial Registration

ClinicalTrials.gov Identifier: NCT04885530.

Leukotriene receptor antagonists as add-on therapy to antihistamines for urticaria: Systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The benefits and harms of adding antileukotrienes to H1 antihistamines (AHs) for the management of urticaria (hives, itch, and/or angioedema) remain unclear.

OBJECTIVE

We sought to systematically synthesize the treatment outcomes of antileukotrienes in combination with AHs versus AHs alone for acute and chronic urticaria.

METHODS

As part of updating American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters urticaria guidelines, we searched Medline, Embase, Central, LILACS, WPRIM, IBECS, ICTRP, CBM, CNKI, VIP, Wanfang, US Food and Drug Administration, and European Medicines Agency databases from inception to December 18, 2023, for randomized controlled trials (RCTs) evaluating antileukotrienes and AHs versus AHs alone in patients with urticaria. Paired reviewers independently screened citations, extracted data, and assessed risk of bias. Random effects models pooled effect estimates for urticaria activity, itch, wheal, sleep, quality of life, and harms. The GRADE approach informed certainty of evidence ratings. The study was registered at the Open Science Framework (osf.io/h2bfx/).

RESULTS

Thirty-four RCTs enrolled 3324 children and adults. Compared to AHs alone, the combination of a leukotriene receptor antagonist with AHs probably modestly reduces urticaria activity (mean difference, -5.04; 95% confidence interval, -6.36 to -3.71; 7-day urticaria activity score) with moderate certainty. We made similar findings for itch and wheal severity as well as quality of life. Adverse events were probably not different between groups (moderate certainty); however, no RCT reported on neuropsychiatric adverse events.

CONCLUSION

Among patients with urticaria, adding leukotriene receptor antagonists to AHs probably modestly improves urticaria activity with little to no increase in overall adverse events. The added risk of neuropsychiatric adverse events in this population with leukotriene receptor antagonists is small and uncertain.

Effectiveness of In-Home, Augmented Reality-Based Telerehabilitation After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Background

New digital technology-based rehabilitation may be a viable option for patients after anterior cruciate ligament reconstruction (ACLR), with advantages such as easy access to treatment and learning as well as cost-effectiveness.

Purpose

To investigate the effects of an augmented reality (AR)-based, telerehabilitation system in patients after ACLR compared with a brochure-based rehabilitation program in terms of patient-reported outcomes and functional performance measures.

Study Design

Randomized controlled trial; Level of evidence, 2.

Methods

This was a multicenter, assessor-blinded study. Enrolled participants were allocated randomly to either the intervention group, who underwent AR-based telerehabilitation system, or to the control group, who underwent a brochure-based rehabilitation program with a self-log. Both groups performed the same postoperative rehabilitation exercise protocol. Subjective knee function was assessed using the International Knee Documentation Committee (IKDC) as the primary outcome; secondary outcomes were a numeric rating scale for pain, the EuroQol 5-Dimension 5-Level, isometric knee strength, range of motion, and the single-leg hop test. The intervention group also completed a satisfaction survey. Follow-up was conducted at 2, 6, 12, and 24 weeks postoperatively.

Results

A total of 28 patients were enrolled in each group; 1 patient in the control group was lost to follow-up. Patients in both groups demonstrated improvement on all outcomes over time. There were no significant between-group differences in the IKDC score from baseline to 12 weeks postoperatively. The intervention group saw a greater increase in the relative isometric strength of the quadriceps on the involved limb at 6, 12, and 24 weeks postoperatively (P < .05 for all). No significant group differences were observed in the remaining secondary outcomes.

Conclusion

Study findings indicated that patients who underwent AR-based telerehabilitation in the early rehabilitation phase after ACLR demonstrated similar improvements as those who followed a brochure-based rehabilitation program and had a quicker recovery of knee extensor strength.

Registration

NCT04513327 (ClinicalTrials.gov identifier).

Protocol of a randomized controlled trial examining psychosocial enhancement and standard medication treatment for co-occurring opioid use and mental health disorders: A half fractional factorial randomized controlled trial

BACKGROUND

The opioid epidemic disproportionately affects individuals with co-occurring opioid use and mental health disorders (COD), who often have poor treatment engagement. Multicomponent treatment models are popular solutions to increase treatment access and engagement for those with COD. Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION) is a hybrid multicomponent linkage and treatment approach that provides assertive community outreach combined with psychosocial treatment. This protocol paper describes a randomized controlled trial comparing MISSION and medication for opioid use disorder (MOUD), its multicomponent parts along with MOUD, and MOUD treatment as usual (TAU) to assess improvements in health and social outcomes.

METHODS

This study will use a half fractional factorial design and randomize 1000 patients with COD to one of five treatment conditions: (1) the full MISSION intervention plus MOUD; (2-4) a combination of two out of three MISSION components plus MOUD; or (5) TAU. Secondary aims include examination of mechanisms of action, economic evaluation of the implementation of MISSION and/or its components plus MOUD versus TAU, and exploratory predictive modeling to match optimal MISSION parts with patient needs.

DISCUSSION

This randomized controlled trial will help determine the effectiveness of MISSION (or its parts) and MOUD compared to TAU to improve engagement in treatment, substance use, and mental health symptoms. This trial is the first to compare MISSION and its parts with MOUD versus TAU in a real-world treatment scenario to determine which components are necessary and sufficient to drive treatment outcomes according to patient needs.

Effects of a Physical Exercise Program on Young People and Adults with Autism Spectrum Disorder-A Study Protocol

Background/Objectives: Physical exercise (PE) has been shown to have positive effects on the symptoms associated with autism spectrum disorder (ASD). However, there is still no consensus on the most appropriate PE intervention model. With this in mind, we developed a program with the aim of determining the effects of PE on physical fitness, with a view to applying it as a potential treatment. Methods: Using an experimental methodology, this research work will recruit 18 institutionalized young people and adults who will be allocated to one of two groups, namely (i) the youth training group and (ii) the adult training group, using low-cost materials. Both intervention groups will perform 90 min of training per session, twice a week, for 12 weeks. Evaluations will be carried out at baseline and month 3. The impact of the exercise program will be assessed based on the variables of anthropometry, body composition, cardiovascular response, and cardiorespiratory fitness. Results: The results of this study will contribute to the development of more effective strategies, prescription recommendations, and interventions as a guarantee in future programs of better and greater adherence to PE by institutionalized individuals with ASD. Conclusions: In addition, we intend to make the PE program available if it promotes positive effects in the target population.

Cyanoacrylate versus Collagen Membrane as a Sealing for Alveolar Ridge Preservation: A Randomized Clinical Trial

This study involved a randomized clinical trial that included 140 patients. Alveolar ridge preservation was performed with xenografts. Sealing in the control group consisted of a collagen membrane versus cyanoacrylate in the test group. The dental implants were placed immediately after extraction. The variables were evaluated at 3, 12, and 18 months of follow-up. Pearson's chi-squared test was used for qualitative variables and the Student t-test for related samples was used for quantitative variables. The change in buccolingual alveolar bone width was significantly greater in the CMX group than in the CX group after three months (p < 0.005). However, significance was not reached at the other follow-up timepoints (p > 0.005). CAL showed significantly greater values in the CMX group than in the CX group (p < 0.005), and MBL proved greater in the CMX group than in the CX group, with p < 0.001. Five membrane exposures were recorded in the CMX group. Cyanoacrylate as a sealing method for alveolar ridge preservation seems to afford better clinical and radiological results than collagen membrane.

Public e-learning opportunities in anesthesia on YouTube

Background

The increasing knowledge in medicine makes continuous education for clinicians necessary more than ever. The range of skills to be covered in anesthesia is constantly growing. How to optimize complex training in practical skills in an increasingly economized environment remains unclear. The extent and suitability to which video platforms assist in learning basic skills in anesthesia has not been investigated yet.

Methods

To identify appropriate videos on YouTube, we conducted a search (May 1st 2023), including common combinations of synonymous terms, and checked up to the 50th result for relevance. Videos initially deemed suitable were archived and evaluated to exclude duplicates. All included videos were subsequently scrutinized for content. For this purpose, a validated checklist to assess procedural and didactic content was used. Data analysis involved assessing interrater reliability, Spearman's rho test, and linear regression analysis.

Results

We were able to include 222 videos related to 16 basic skills. The low number of videos found on specific skills was striking. The level of fulfillment illustrating a practical skill was repeatedly found <60%. The consistency of the questionnaire was moderate (Fleiss kappa 0.59). Video runtime displayed a significant correlation (p < 0.001) with the number of items accomplished on procedural (|ρ| = 0.442, R 2 = 0.196) and didactic items (|ρ| = 0.452, R 2 = 0.153). The professional context of the content creators showed no influence.

Conclusion

The quantity of available material on specific basic anesthesiologic skills varied drastically. In addition, the videos available often revealed significant shortcomings, making it challenging to easily assess the quality of the content. The vast majority of evaluated videos did not reflect the intended approach in a scientifically correct manner or were entirely unsuitable for displaying the procedural requirements.

Open versus robotic retromuscular ventral hernia repair: outcomes of the ORREO prospective randomized controlled trial

BACKGROUND

Robotic retromuscular ventral hernia repair (rRMVHR) potentially combines the best features of open and minimally invasive VHR: myofascial release with abdominal wall reconstruction (AWR) with the lower wound morbidity of laparoscopic VHR. Proliferation of this technique has outpaced the data supporting this claim. We report 2-year outcomes of the first randomized controlled trial of oRMVHR vs rRMVHR.

METHODS

Single-center randomized control trial of open vs rRMVHR. 100 patients were randomized (50 open, 50 robotic). We included patients > 18 y/o with hernias 7-15 cm with at least one of the following: diabetes, chronic obstructive pulmonary disease (COPD), body mass index (BMI) ≥ 30, or current smokers. Primary outcome was occurrence of a composite outcome of surgical site infection (SSI), non-seroma surgical site occurrence (SSO), readmission, or hernia recurrence. Secondary outcomes were length of stay, any SSI or SSO, SSI/SSOPI, operative time, patient reported quality of life, and cost. Analysis was performed in an intention-to-treat fashion. Study was funded by a grant from Society of American Gastrointestinal and Endoscopic Surgeons.

RESULTS

90 patients were available for 30-day and 62 for 2-year analysis (rRMVHR = 46 and 32, oRMVHR = 44 and 30). Hernias in the open group were slightly larger (10 vs 8 cm, p = 0.024) and more likely to have prior mesh (36.4 vs 15.2%; p = 0.030), but were similar in length, prior hernia repairs, mesh use, and myofascial release. There was no difference in primary composite outcome between oRMVHR and rRMVHR (20.5 vs 19.6%, p = 1.000). Median length of stay was shorter for rRMVHR (1 vs 2 days; p < 0.001). All patients had significant improvement in quality of life at 1 and 2 years. Other secondary outcomes were similar.

CONCLUSION

There is no difference in a composite outcome including SSI, SSOPI, readmission, and hernia recurrence between open and robotic RMVHR.

A phase II trial examining the safety and preliminary efficacy of repetitive transcranial magnetic stimulation (rTMS) for people living with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological condition and the leading cause of non-traumatic disability in young adults. MS pathogenesis leads to the death of oligodendrocytes, demyelination, and progressive central nervous system neurodegeneration. Endogenous remyelination occurs in people with MS (PwMS) but is insufficient to repair the damage. Our preclinical studies in mice indicate that endogenous remyelination can be supported by the delivery of repetitive transcranial magnetic stimulation (rTMS). Our phase I trial concluded that 20 sessions of rTMS, delivered over 5 weeks, are safe and feasible for PwMS. This phase II trial aims to investigate the safety and preliminary efficacy of rTMS for PwMS.

METHODS

Participants must be aged 18-65 years, diagnosed with MS by a neurologist, stable and relapse free for 6 months, have an Extended Disability Status Scale (EDSS) between 1.5 and 6 (inclusive), willing to travel to a study site every weekday for 4 consecutive weeks, and able to provide informed consent and access the internet. Participants from multiple centres will be randomised 2:1 (rTMS to sham) stratified by sex. The intervention will be delivered with a Magstim Rapid2 stimulator device and circular 90-mm coil or MagVenture MagPro stimulator device with C100 circular coil, positioned to stimulate a broad area including frontal and parietal cortices. For the rTMS group, pulse intensity will be set at 18% (MagVenture) or 25% (Magstim) of maximum stimulator output (MSO), and rTMS applied as intermittent theta burst stimulation (iTBS) (~ 3 min per side; 600 pulses). For the sham group, the procedure will be the same, but the intensity is set at 0%. Each participant will attend 20 intervention sessions over a maximum of 5 weeks. Outcome measures include MS Functional Composite Score (primary), Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Quality of Life, and Pittsburgh Sleep Quality Index/Numeric Rating Scale and adverse events (secondary) and advanced MRI metrics (tertiary). Outcomes will be measured at baseline and after completing the intervention.

DISCUSSION

This study will determine if rTMS can improve functional outcomes or other MS symptoms and determine whether rTMS has the potential to promote remyelination in PwMS.

TRIAL REGISTRATION

Registered with Australian New Zealand Clinical Trials Registry, 20 January 2022; ACTRN12622000064707.

Lu-177 PSMA vs Comparator Treatments and Survival in Metastatic Castration-Resistant Prostate Cancer

Importance

Observed treatment effects on overall survival (OS) differed substantially in the first 2 randomized clinical trials of lutetium Lu 177 vipivotide tetraxetan (Lu-177) prostate-specific membrane antigen (PSMA) in metastatic castration-resistant prostate cancer.

Objective

To investigate factors associated with the observed difference in treatment effects on OS, including differences in the risk of crossover from randomized treatment after disease progression.

Design, Setting, and Participants

This comparative effectiveness study used individual participant data from 2 randomized clinical trials, TheraP (A Randomised Phase 2 Trial of 177Lu-PSMA617 Theranostic Versus Cabazitaxel in Progressive Metastatic Castration Resistant Prostate Cancer [ANZUP Protocol 1603]) (n = 200), recruited from February 2018 to September 2019 in Australia, and published data from VISION (An International, Prospective, Open Label, Multicenter, Randomized Phase 3 Study of 177Lu-PSMA-617 in the Treatment of Patients With Progressive PSMA-Positive Metastatic Castration-Resistant Prostate Cancer) (n = 831), recruited from June 2018 to October 2019 in North America and Europe. Individual participant data for OS were reconstructed from VISION using the published survival curves. Data were analyzed February 6, 2018, to December 31, 2021, for TheraP and June 4, 2018, to January 27, 2021, for VISION.

Interventions

TheraP randomized participants to receive treatment with Lu-177 PSMA or cabazitaxel. VISION randomized participants to receive treatment with or without Lu-177 PSMA in addition to physicians' choice of protocol-permitted treatments (PPT; approved hormonal treatments [such as abiraterone and enzalutamide], bisphosphonates, radiotherapy, denosumab, or glucocorticoids), excluding cabazitaxel.

Main Outcomes and Measures

Patient characteristics, treatment protocols, and OS outcomes of the 2 trials were compared. Estimates of the effect on OS from TheraP were adjusted for crossover from randomly assigned treatment using a rank-preserving structural failure time model (RPSFTM) and inverse probability of censoring weights (IPCW) methods.

Results

The 200 participants in TheraP and 831 participants in VISION were similar in age (median [range], 72 [49-86] vs 71 [40-94] years). Improved OS was observed in the comparator treatment group (cabazitaxel) in TheraP compared with VISION (PPT) (hazard ratio [HR], 0.53 [95% CI, 0.39-0.71]). The Lu-177 PSMA treatment groups in TheraP and VISION had similar OS (HR, 0.92 [95% CI, 0.70-1.19]). In TheraP, 20 of 101 participants in the cabazitaxel group crossed over to Lu-177 PSMA, while 32 of 99 participants in the Lu-177 PSMA arm crossed over to cabazitaxel. No statistically significant differences in OS between the Lu-177 PSMA and cabazitaxel groups of TheraP were observed after controlling for crossover to cabazitaxel: RPSFTM HR, 0.97 (95% CI, 0.60-1.58); IPCW HR, 0.92 (95% CI, 0.65-1.32); RPSFTM HR, 0.97 (95% CI, 0.60-1.58) and IPCW HR, 0.82 (95% CI, 0.54-1.24) for crossover to Lu-177 PSMA; RPSFTM HR, 0.96 (95% CI, 0.53-1.74) and IPCW HR, 0.82 (95% CI, 0.53-1.27) for crossover to either Lu-177 PSMA or cabazitaxel.

Conclusions and Relevance

Findings of this secondary analysis of the TheraP and VISION randomized clinical trials suggest that the choice of comparator treatments (ie, cabazitaxel vs PPT) may explain the difference in the observed effect of Lu-177 PSMA on OS between the 2 trials. Causal inference methods such as RPSFTM and IPCW may help rule out crossover as a plausible explanation.

Safety of acamprosate for alcohol use disorder after liver transplant: A pilot randomized controlled trial

Acamprosate is a therapy for alcohol use disorder, but data on feasibility and safety in recipients of liver transplants are lacking. This was a single-center unblinded prospective pilot randomized controlled trial of adults (≥18 y) with liver transplant for alcohol-associated liver disease enrolled between 2021 and 2023, who were randomized 2:1 to the intervention of acamprosate (666 mg dose 3 times daily) or standard of care (SOC) over 14 weeks. Outcomes included safety (prevalence of adverse events [AEs]), feasibility (weekly survey response rate >60%), adherence (self-reported acamprosate use >60%), and efficacy (reduction in Penn Alcohol Craving Scale), and relapse-blood phosphatidylethanol (≥20 ng/mL/reported alcohol use) evaluated by standardized weekly surveys. The efficacy analysis was done in both the intention-to-treat (excluding withdrawals before medication administration) and per-protocol population (excluding withdrawals/<4 weeks participation). Of 78 participants who were approached, 30 enrolled (19 acamprosate and 11 SOC) with similar baseline characteristics. Eight participants withdrew (6 acamprosate before medication administration and 2 SOC). AEs were similar between acamprosate and SOC groups (92.3% vs. 90.0%, p > 0.99), including grade 3 AEs (53.9% vs. 60.0%, p > 0.99) with no reported grade 4/5 AEs. Survey response rates were similar in acamprosate versus SOC groups (61.0% vs. 76.0%, p = 0.19), and 69.0% were acamprosate adherents. Baseline Penn Alcohol Craving Scale values were low with no difference by the group in median absolute change in Penn Alcohol Craving Scale for intention-to-treat (0, IQR: -4 to 0 vs. 0, IQR: 0-0, p = 0.32), and per-protocol analyses (-1, IQR: -6 to 0 vs. 0, IQR: -0 to 0, p = 0.36). There was no reported or biochemical evidence of alcohol relapse. In this pilot study, preliminary data suggest that acamprosate may be safe and feasible. These data can inform larger studies and clinician efforts to address alcohol use disorder in post-liver transplant care (ClinicalTrials.gov, Number: NCT06471686).

N-Butyl-2-Cyanoacrylate Adhesive Versus Absorbable Tacks in Laparoscopic Groin Hernia Repair: A Multicenter Randomized Clinical Trial

Objective

We aimed to determine whether n-butyl-2-cyanoacrylate (NB2C) adhesive is a safe and effective mechanism for nonpenetrating mesh and peritoneal fixation during laparoscopic groin hernia repair.

Background

Chronic pain after laparoscopic groin hernia repair has been associated with penetrating fixation, but there had been no US Food and Drug Administration-approved devices for nonpenetrating fixation in this context.

Methods

Patients undergoing laparoscopic transabdominal preperitoneal (TAP) or totally extraperitoneal (TEP) groin hernia repair with mesh at 1 of 5 academic medical centers were randomized to mesh (TAP/TEP) and peritoneal (TAP) fixation with NB2C adhesive or absorbable tacks. The primary outcome was improvement in pain (visual analog scale [VAS]) at 6 months. The noninferiority margin was 0.9 (α = 0.025; β = 80%). Recurrence, successful use of the device, quality of life, and rates of adverse events (AEs) were secondary outcomes.

Results

From 2019 to 2021, 284 patients were randomized to either NB2C adhesive or absorbable tacks (n = 142/142). Patient and hernia characteristics were comparable, and 65% were repaired using a TAP approach. The difference in VAS improvement at 6 months with NB2C adhesive was not inferior to absorbable tacks in intention-to-treat and per-protocol analyses, respectively (0.25 [95% CI, -0.33 to 0.82]; P = 0.013; 0.22 [95% CI, -0.36 to 0.80], noninferiority P = 0.011). There were no differences in secondary outcomes including recurrence, successful use of each device to fixate the mesh and peritoneum, quality of life, and additional VAS pain scores. Rates of adverse and serious AEs were also comparable.

Conclusions

NB2C adhesive is safe and effective for mesh fixation and peritoneal closure during laparoscopic groin hernia repair.

Intravenous Lidocaine for Refractory Pain in Patients With Pancreatic Ductal Adenocarcinoma and Chronic Pancreatitis: A Multicenter Prospective Nonrandomized Pilot Study

INTRODUCTION

Refractory pain is a major clinical problem in patients with pancreatic ductal adenocarcinoma (PDAC) and chronic pancreatitis (CP). New, effective therapies to reduce pain are urgently needed. Intravenous lidocaine is used in clinical practice in patients with PDAC and CP, but its efficacy has not been studied prospectively.

METHODS

Multicenter prospective nonrandomized pilot study included patients with moderate or severe pain (Numeric Rating Scale ≥ 4) associated with PDAC or CP in 5 Dutch centers. An intravenous lidocaine bolus of 1.5 mg/kg was followed by continuous infusion at 1.5 mg/kg/hr. The dose was raised every 15 minutes until treatment response (up to a maximum 2 mg/kg/hr) and consecutively administered for 2 hours. Primary outcome was the mean difference in pain severity, preinfusion, and the first day after (Brief Pain Inventory [BPI] scale 1-10). A BPI decrease ≥1.3 points was considered clinically relevant.

RESULTS

Overall, 30 patients were included, 19 with PDAC (63%) and 11 with CP (37%). The mean difference in BPI at day 1 was 1.1 (SD ± 1.3) points for patients with PDAC and 0.5 (SD ± 1.7) for patients with CP. A clinically relevant decrease in BPI on day 1 was reported in 9 of 29 patients (31%), and this response lasted up to 1 month. No serious complications were reported, and only 3 minor complications (vertigo, nausea, and tingling of mouth). Treatment with lidocaine did not impact quality of life.

DISCUSSION

Intravenous lidocaine in patients with painful PDAC and CP did not show an overall clinically relevant reduction of pain. However, this pilot study shows that the treatment is feasible in this patient group and had a positive effect in a third of patients which lasted up to a month with only minor side effects. To prove or exclude the efficacy of intravenous lidocaine, the study should be performed in a study with a greater sample size and less heterogeneous patient group.

Efficacy of clear aligners vs rapid palatal expanders on palatal volume and surface area in mixed dentition patients: A randomized controlled trial

INTRODUCTION

This study aimed to evaluate the efficacy of Invisalign First Phase I treatment compared with tooth-borne rapid maxillary expansion (RME) in mixed dentition patients by examining changes in palatal volume, palatal surface area, and maxillary interdental transverse measurements.

METHODS

In this open-label, 2-arm, parallel, randomized controlled trial, patients with a posterior transverse discrepancy ≤6 mm were allocated into the clear aligner therapy (CAT) group (Invisalign First Phase I treatment) and RME group (tooth-borne RME) according to a computer-generated randomization list immediately before the start of treatment. Digital models were obtained before the beginning of the treatment (T0) and at the end of the retention period/treatment (T1) using an intraoral scanner. Palatal volume was measured as the primary outcome, and palatal surface area and intermolar and intercanine transverse widths at the cusps and gingival level were measured as secondary outcomes. Patients and interventionists were not blinded because of the nature of the intervention.

RESULTS

Out of 50 patients, 41 (19 males and 22 females; mean age, 8.12 ± 1.53 years) were enrolled and divided into 2 groups: 20 in the CAT group and 21 in the RME group. Two participants did not receive the allocated intervention for different reasons (1 patient discontinued the intervention in the CAT group, and another patient was lost to follow-up in the RME group). Thus, 19 patients (5 males and 14 females; mean age, 8.48 ± 1.42 years) were analyzed from the CAT group, and 20 patients (12 males and 8 females; mean age, 7.83 ± 1.19 years) from the RME group. Regarding intragroup comparisons, all outcome measures significantly increased from T0 to T1 in both groups. In terms of intergroup comparisons, there were no significant differences in the variation (Δ) of outcome measures between the 2 groups from T0 to T1, except for the intermolar width at the gingival level (P <0.005). The change in palatal volume was 532.01 ±540.52 mm³ for the RME group and 243.95 ± 473.24 mm³ for the CAT group (P = 0.084), with a moderate effect size (d = 0.57).

CONCLUSIONS

RME showed trends favoring better outcomes compared with Invisalign First Phase I treatment across all assessed measures. The only parameter that showed statistically significant differences between the 2 groups was variation in intermolar width at the gingival level, suggesting the occurrence of buccal tipping in patients undergoing Invisalign First Phase I treatment.

TRIAL REGISTRATION

The trial was registered at ClinicalTrial.gov (no. NCT04760535).

Personalised blood pressure management during major noncardiac surgery and postoperative neurocognitive disorders: a randomised trial

Background

It remains unknown whether there is a causal relationship between intraoperative hypotension and postoperative neurocognitive disorders. We tested the hypothesis that personalised-compared to routine-intraoperative blood pressure management reduces the incidence of postoperative neurocognitive disorders in patients having major noncardiac surgery.

Methods

In this single-centre trial, 328 elective major noncardiac surgery patients were randomly allocated to receive personalised blood pressure management (i.e. maintaining intraoperative mean arterial pressure [MAP] above preoperative baseline MAP from automated 24-h blood pressure monitoring) or routine blood pressure management (i.e. maintaining MAP above 65 mm Hg). The primary outcome was the incidence of neurocognitive disorders (composite of delayed neurocognitive recovery and delirium) between postoperative days 3 and 7.

Results

The primary outcome, neurocognitive disorders, occurred in 18 of 147 patients (12%) assigned to personalised and 21 of 148 patients (14%) assigned to routine blood pressure management (odds ratio [OR]=0.84, 95% confidence interval [CI]: 0.40-1.75, P=0.622). Delayed neurocognitive recovery occurred in 17 of 146 patients (12%) assigned to personalised and 17 of 145 patients (12%) assigned to routine blood pressure management (OR=0.99, 95% CI: 0.45-2.17, P=0.983). Delirium occurred in 2 of 157 patients (1%) assigned to personalised and 4 of 158 patients (3%) assigned to routine blood pressure management (OR=0.50, 95% CI: 0.04-3.53, P=0.684).

Conclusions

Personalised intraoperative blood pressure management maintaining preoperative baseline MAP neither reduced the incidence of the composite primary outcome neurocognitive disorders between postoperative days 3 and 7 nor the incidences of the components of the composite primary outcome-delayed neurocognitive recovery and delirium-compared to routine blood pressure management in patients having major noncardiac surgery.

Clinical trial registration

ClinicalTrials.gov (NCT03442907).

Stimulation Therapy to Induce Mothers: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

More than 1 million women have their labor induced in the United States each year, and synthetic oxytocin infusion is the most common method used. However, compared to spontaneous labor, medical induction is resource intensive, has increased obstetric risks, and is associated with less successful breastfeeding. In contrast to the endogenous oxytocin hormone, which is released in a pulsatile fashion in the brain, synthetic oxytocin is continuously infused intravenously, resulting in important limitations related to efficacy, safety, and cost. Akin to spontaneous labor contractions, infant suckling of the breast nipple is known to stimulate the pulsatile release of endogenous oxytocin from the posterior pituitary gland. Nipple stimulation therapy via an electric breast pump similarly stimulates endogenous oxytocin release and may be a favorable inpatient method for patients undergoing labor induction.

OBJECTIVE

This study aims to examine whether inpatient nipple stimulation therapy is an efficacious labor induction method that increases the likelihood of spontaneous vaginal delivery and sustained breastfeeding and determine whether it is a cost-effective approach.

METHODS

This is a multicenter, pragmatic, open-label, parallel-group randomized controlled trial of nulliparous patients with singleton gestations ≥36 weeks undergoing labor induction. This trial compares inpatient nipple stimulation therapy via an electric breast pump versus immediate synthetic oxytocin infusion without nipple stimulation. This trial including 988 nulliparas will provide adequate statistical power to detect clinically meaningful differences in delivery mode and breast milk as the sole source of nutrition for newborns at hospital discharge or 72 hours after birth.

RESULTS

The project received pilot funding in 2021 and full funding in 2023. Enrollment for this study began in November 2021 at a single site, and as of May 2024, recruitment is underway at 3 study sites. It is anticipated that enrollment will be completed by late 2026.

CONCLUSIONS

Successful completion of this trial will provide rigorous data to determine whether inpatient nipple stimulation therapy with an electric breast pump can improve the way we induce labor and positively impact breastfeeding success and early infant nutrition through lactation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05079841; https://clinicaltrials.gov/study/NCT05079841.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63463.

Ultrasound-guided supraclavicular block versus Bier block for emergency reduction of upper limb injuries: statistical analysis plan

BACKGROUND

Ultrasound-guided supraclavicular block (UGSCB) is an emerging technique gaining interest amongst emergency physicians that provides regional anaesthesia to the upper limb to tolerate painful procedures. It offers an alternative to the more traditional technique of a Bier block (BB). However, the effectiveness or safety of UGSCB when performed in the emergency department (ED) is unclear.

METHODS

SUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label non-inferiority randomised controlled trial comparing the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with upper limb fracture and/or dislocation requiring closed reduction in ED were randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part was performed and immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure.

RESULTS

Primary outcome analysis will be performed using both the intention-to-treat and per-protocol populations. The between-group difference in maximum pain intensity will be assessed using linear regression modelling with trial group allocation (UGSCB vs BB) included as a main affect. A pre-specified non-inferiority margin of 20 mm on the VAS scale will be used to establish non-inferiority of UGSCB compared to BB.

CONCLUSION

SUPERB is the first randomised controlled trial to investigate the effectiveness and safety of UGSCB in the ED. The trial has the potential to demonstrate that UGSCB is an alternative safe and effective option for the management of upper extremity emergencies in the ED.

Decompression alone or with fusion for degenerative lumbar spondylolisthesis (Nordsten-DS): five year follow-up of a randomised, multicentre, non-inferiority trial

OBJECTIVE

To assess whether decompression alone is non-inferior to decompression with instrumented fusion five years after primary surgery in patients with degenerative lumbar spondylolisthesis.

DESIGN

Five year follow-up of a randomised, multicentre, non-inferiority trial (Nordsten-DS).

SETTING

16 public orthopaedic and neurosurgical clinics in Norway.

PARTICIPANTS

Patients aged 18-80 years with symptomatic lumbar spinal stenosis and a spondylolisthesis of 3 mm or more at the stenotic level.

INTERVENTIONS

Decompression surgery alone and decompression with additional instrumented fusion (1:1).

MAIN OUTCOME MEASURES

The primary outcome was a 30% or more reduction in Oswestry disability index from baseline to five year follow-up. The predefined non-inferiority margin was a -15 percentage point difference in the proportion of patients who met the primary outcome. Secondary outcomes included the mean change in Oswestry disability index, Zurich claudication questionnaire, numeric rating scale for leg and back pain, and EuroQol Group 5-Dimension (EQ-5D-3L) questionnaire.

RESULTS

From 12 February 2014 to 18 December 2017, 267 participants were randomly assigned to decompression alone (n=134) and decompression with instrumented fusion (n=133). Of these, 230 (88%) responded to the five year questionnaire: 121 in the decompression group and 109 in the fusion group. Mean age at baseline was 66.2 years (SD 7.6), and 69% were women. In the modified intention-to-treat analysis with multiple imputation of missing data, 84 (63%) of 133 people in the decompression alone group and 81 (63%) of 129 people in the fusion group had a at least a 30% reduction in Oswestry disability index, a difference of 0.4 percentage points. (95% confidence interval (CI) -11.2 to 11.9). The respective results of the per protocol analysis were 65 (65%) of 100 in the decompression alone group and 59 (66%) of 89 in the fusion group, a difference of -1.3 percentage points (95% CI -14.5 to 12.2). Both 95% CIs were higher than the predefined non-inferiority margin of -15%. The mean change in Oswestry disability index from baseline to five years was -17.8 in both groups (mean difference 0.02 (95% CI -3.8 to 3.9)). Results of the other secondary outcomes were in the same direction as the primary outcome. From two to five year follow-up, a new lumbar operation occurred in six (5%) of 123 people in the decompression group and 11 (10%) of 113 people in the fusion group, with a total from baseline to five years of 21 (16%) of 129 people and 23 (18%) of 125, respectively.

CONCLUSIONS

In participants with degenerative spondylolisthesis, decompression alone was non-inferior to decompression with instrumented fusion five years after primary surgery. Proportions of subsequent surgeries at the index level or an adjacent lumbar level were no different between the groups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02051374.

Totally laparoscopic versus laparoscopy-assisted distal gastrectomy: the KLASS-07: a randomized controlled trial

BACKGROUNDS

Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). The authors performed an RCT to confirm if TLDG is different from LADG.

METHODS

The KLASS-07 trial is a multi-centre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enroled from 21 cancer care centres in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the KLASS-07 trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was quality of life (QoL) for 1 year. This trial is registered at ClinicalTrials.gov (NCT03393182).

RESULTS

Four hundred forty-two patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P= 0.006; and 0.5% vs. 4.3%, P= 0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P< 0.05). However, these QoL differences were resolved at 1 year.

CONCLUSIONS

The KLASS-07 trial confirmed that TLDG is not different from LADG in terms of postoperative complications but has the advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months.

The effects of a digital lifestyle intervention in patients with hypertension: Results of a pilot randomized controlled trial

In this pilot study, the authors investigated the preliminary effectiveness of the digital lifestyle intervention, actensio (mementor DE GmbH), in treating arterial hypertension. Adults with arterial hypertension were randomly assigned to an intervention group (actensio + standard care) or a control group (waiting list + standard care) in a 1:1 ratio. Primary and secondary endpoints were assessed at baseline (t0) and 3 months post-randomization (t1). The primary endpoint was average systolic blood pressure, measured at home for 1 week. Secondary endpoints included patient engagement (measured using the "patient activation measure"; PAM-13), average diastolic blood pressure, and heart rate. All endpoints were analyzed using ANCOVA models, following an intention-to-treat approach, while adjusting for baseline values. Missing data were estimated using multiple imputation models. A total of N = 102 participants (f = 59, age = 52.94 ± 9.01) were randomized to either the intervention (IG; N = 52) or the control group (CG; N = 50), of which N = 80 completed the blood pressure diary, and N = 81 the PAM-13 at t1. Between-group comparisons showed an average group difference in systolic blood pressure of -5.06 mm Hg (95% CI = -8.71 to -1.41, p = .013) between the intervention group (M = 137.37 ± 10.13) and the control group (M = 142.35 ± 11.23). Average group difference for patient engagement was 3.35 points with a trend towards statistical significance (95% CI = -018 to 6.89, p = .064), favoring the intervention group (MIG = 79.38 ± 9.44 vs. MCG = 75.45 ± 10.62). There were no group differences in diastolic blood pressure (-1.78 mm Hg; 95% CI = -4.50 to 0.95, p = .402) and heart rate (-0.684; 95% CI = -3.73 to 2.36, p = 0.683). The results of the present pilot study confirm the preliminary effectiveness of the digital lifestyle intervention, actensio, in reducing high blood pressure in patients with hypertension.

Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN for OMIs 2024

PURPOSE

Although comprehensive and widespread guidelines on how to conduct systematic reviews of outcome measurement instruments (OMIs) exist, for example from the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) initiative, key information is often missing in published reports. This article describes the development of an extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guideline: PRISMA-COSMIN for OMIs 2024.

METHODS

The development process followed the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines and included a literature search, expert consultations, a Delphi study, a hybrid workgroup meeting, pilot testing, and an end-of-project meeting, with integrated patient/public involvement.

RESULTS

From the literature and expert consultation, 49 potentially relevant reporting items were identified. Round 1 of the Delphi study was completed by 103 panelists, whereas round 2 and 3 were completed by 78 panelists. After 3 rounds, agreement (≥ 67%) on inclusion and wording was reached for 44 items. Eleven items without consensus for inclusion and/or wording were discussed at a workgroup meeting attended by 24 participants. Agreement was reached for the inclusion and wording of 10 items, and the deletion of 1 item. Pilot testing with 65 authors of OMI systematic reviews further improved the guideline through minor changes in wording and structure, finalized during the end-of-project meeting. The final checklist to facilitate the reporting of full systematic review reports contains 54 (sub)items addressing the review's title, abstract, plain language summary, open science, introduction, methods, results, and discussion. Thirteen items pertaining to the title and abstract are also included in a separate abstract checklist, guiding authors in reporting for example conference abstracts.

CONCLUSION

PRISMA-COSMIN for OMIs 2024 consists of two checklists (full reports; abstracts), their corresponding explanation and elaboration documents detailing the rationale and examples for each item, and a data flow diagram. PRISMA-COSMIN for OMIs 2024 can improve the reporting of systematic reviews of OMIs, fostering their reproducibility and allowing end-users to appraise the quality of OMIs and select the most appropriate OMI for a specific application. NOTE: In order to encourage its wide dissemination this article is freely accessible on the web sites of the journals: Health and Quality of Life Outcomes; Journal of Clinical Epidemiology; Journal of Patient-Reported Outcomes; Quality of Life Research.

Effect of postoperative intermittent boluses of subcostal quadratus lumborum block on pulmonary function recovery and analgesia after gastrectomy: a randomized controlled clinical trial

BACKGROUND

Following the gastrectomy, the reduction in pulmonary function is partly attributed to postoperative pain. Subcostal quadratus lumborum block (QLB) has recently emerged as a promising component in multimodal analgesia. We aimed to assess the impact of intermittent boluses of subcostal QLB on pulmonary function recovery and analgesic efficacy after gastrectomy.

METHODS

Sixty patients scheduled for gastrectomy were randomly assigned to either control group (multimodal analgesia) or intervention group (intermittent boluses of subcostal QLB plus multimodal analgesia). Two primary outcomes included the preservation of forced expiratory volume in the first second (FEV1) and the pain scores (0-10 cm visual analog score) on coughing 24 h postoperatively. We assessed the pulmonary function parameters, pain score, morphine consumption and number of rescue analgesia at a 24-h interval up to 72 h (Day1, Day2, Day3 respectively) as secondary outcomes.

RESULTS

59 patients were analyzed in a modified intention-to-treat set. The preservation of FEV1 (median difference: 4.0%, 97.5% CI: -5.7 to 14.9, P = 0.332) and pain scores on coughing (mean difference: 0.0 cm, 97.5% CI: -1.1 to 1.2, P = 0.924) did not differ significantly between two groups. In the intervention group, the recovery of forced vital capacity (FVC) was faster 72 h after surgery (interaction effect of group*(Day3-Day0): estimated effect (β) =0.30 L, standard error (SE) =0.13, P = 0.025), pain scores at rest were lower in the first 3 days (interaction effect of group*(Day1-Day0): β = - 0.8 cm, SE = 0.4, P = 0.035; interaction effect of group*(Day2-Day0): β = - 1.0 cm, SE = 0.4, P = 0.014; and interaction effect of group*(Day3-Day0): β = - 1.0 cm, SE = 0.4, P values = 0.009 respectively), intravenous morphine consumption was lower during 0-24 h (median difference: -3 mg, 95% CI -6 to -1, P = 0.014) and in total 72 h (median difference: -5 mg, 95% CI -10 to -1, P = 0.019), and the numbers of rescue analgesia was fewer during 24-48 h (median difference: 0, 95% CI 0 to 0, P = 0.043). Other outcomes didn't show statistical differences.

CONCLUSION

Postoperative intermittent boluses of subcostal QLB did not confer advantages in terms of the preservation of FEV1 or pain scores on coughing 24 h after gastrectomy. However, notable effects were observed in analgesia at rest and FVC recovery.

Processed electroencephalography-guided general anesthesia and norepinephrine requirements: A randomized trial in patients having vascular surgery

STUDY OBJECTIVE

Processed electroencephalography (pEEG) may help clinicians optimize depth of general anesthesia. Avoiding excessive depth of anesthesia may reduce intraoperative hypotension and the need for vasopressors. We tested the hypothesis that pEEG-guided - compared to non-pEEG-guided - general anesthesia reduces the amount of norepinephrine needed to keep intraoperative mean arterial pressure above 65 mmHg in patients having vascular surgery.

DESIGN

Randomized controlled clinical trial.

SETTING

University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

PATIENTS

110 patients having vascular surgery.

INTERVENTIONS

pEEG-guided general anesthesia.

MEASUREMENTS

Our primary endpoint was the average norepinephrine infusion rate from the beginning of induction of anesthesia until the end of surgery.

MAIN RESULT

96 patients were analyzed. The mean ± standard deviation average norepinephrine infusion rate was 0.08 ± 0.04 μg kg-1 min-1 in patients assigned to pEEG-guided and 0.12 ± 0.09 μg kg-1 min-1 in patients assigned to non-pEEG-guided general anesthesia (mean difference 0.04 μg kg-1 min-1, 95% confidence interval 0.01 to 0.07 μg kg-1 min-1, p = 0.004). Patients assigned to pEEG-guided versus non-pEEG-guided general anesthesia, had a median time-weighted minimum alveolar concentration of 0.7 (0.6, 0.8) versus 0.8 (0.7, 0.8) (p = 0.006) and a median percentage of time Patient State Index was <25 of 12 (1, 41) % versus 23 (3, 49) % (p = 0.279).

CONCLUSION

pEEG-guided - compared to non-pEEG-guided - general anesthesia reduced the amount of norepinephrine needed to keep mean arterial pressure above 65 mmHg by about a third in patients having vascular surgery. Whether reduced intraoperative norepinephrine requirements resulting from pEEG-guided general anesthesia translate into improved patient-centered outcomes remains to be determined in larger trials.

Effect of shenmai injection on anthracycline-induced cardiotoxicity: A systematic review and meta-analysis

OBJECTIVE

Shenmai injection is a classic herbal prescription, and is often recommended for the treatment of anthracycline-induced cardiotoxicity. However, the efficacy and safety of Shenmai injection for the treatment of anthracycline-induced cardiotoxicity have not been reported.

MATERIALS AND METHODS

We conducted a comprehensive search of eight literature databases and two clinical trial registries, retrieving all randomized controlled trials (RCTs) related to the treatment of anthracycline-induced cardiotoxicity with Shenmai injection from the establishment of the databases to July 1, 2023. Data analysis was performed using the Meta package in RStudio and RevMan 5.4. The GRADE pro3.6.1 software was utilized for assessing the quality of evidence.

RESULTS

A total of 16 RCTs including 2140 patients were included in this study. Meta-analysis showed that Shenmai injection had an advantage in improving ST-T segment changes (RR = 0.28; 95 % CI, 0.20 to 0.39; P < 0.0001) (P < 0.01), creatine kinase isoenzyme (SMD = -3.49; 95 % CI, -5.24 to -1.74; P < 0.0001), Prolonged QT interval (RR = 0.46; 95 % CI, 0.28 to 0.75; P = 0.0018), Low QRS Voltage (RR = 0.44; 95 % CI, 0.27 to 0.71; P = 0.0007), sinus tachycardia (RR = 0.41; 95 % CI, 0.28 to 0.60; P < 0.0001), atrial premature beats (RR = 0.55; 95 % CI, 0.35 to 0.87; P = 0.01), Premature Ventricular Contractions (RR = 0.39; 95 % CI, 0.26 to 0.59; P < 0.0001) and creatine kinase (SMD = -1.43; 95 % CI, -2.57 to -0.29; P < 0.0001) in patients with anthracycline-induced cardiotoxicity. advantage, which was supported by sensitivity analyses, but not in improving left ventricular ejection fraction (MD = 16.01; 95 % CI, -3.10 to 35.12; P = 0.10) and atrioventricular block (RR = 0.49; 95 % CI, 0.24 to 1.03; P = 0.06). The literature included in the study did not refer to data regarding the safety aspects of Shenmai injection, so we do not yet know the safety of Shenmai injection. The results of subgroup analyses suggested that heterogeneity was not related to the administered dose and chemotherapy regimen. The publication bias test showed no publication bias. The quality of evidence for the results ranged from "very low" to "moderate."

CONCLUSION

This study suggests that Shenmai injection is effective in treating anthracycline-induced cardiotoxicity and is a potential treatment for anthracycline-induced cardiotoxicity. However, due to the poor methodological quality of the included RCTs, we recommend rigorous, high-quality, large-sample trials to confirm our findings.

Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial

BACKGROUND

It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery.

METHODS

In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery.

RESULTS

We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03-3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis.

CONCLUSIONS

Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications.

CLINICAL TRIAL REGISTRATION

NCT03021525.

Tendon graft through the coracoid tunnel versus under the coracoid for coracoclavicular/acromioclavicular reconstruction shows no difference in radiographic or patient-reported outcomes

INTRODUCTION

The purpose of this prospective study was to report the outcomes of two different methods in CC and AC reconstruction for the treatment of AC separation using a tendon graft and knot-hiding titanium clavicular implant.

MATERIALS AND METHODS

Twenty-seven patients with Rockwood grade III and V acromioclavicular (AC) separations were randomized into two groups. The primary outcome was whether taking the tendon graft through the coracoid risked a fracture. The following were secondary outcomes: follow-up of clavicular wound healing and Nottingham Clavicle score, Constant score, and Simple Shoulder Test results obtained preoperatively and 24 months postoperatively. The anteroposterior radiographic change between the clavicular and coracoid cortexes and the clavicular tunnel diameter was measured postoperatively and 24 months postoperatively. General patient satisfaction with the outcome (poor, fair, good, or excellent) was assessed 2 years postoperatively.

RESULTS

No coracoid fractures were detected. No issues in clavicular wound healing were detected. The mean Nottingham Clavicle score increased from a preoperative mean of 42.42 ± 13.42 to 95.31 ± 14.20 (P < 0.00). The Constant score increased from a preoperative mean of 50.81 ± 17.77 to 96.42 ± 11.51 (P < 0.001). The Simple Shoulder Test score increased from a preoperative mean of 7.50 ± 2.45 to 11.77 ± 1.18 (P < 0.001). The changes were significant. The coracoclavicular distance increased from 11.88 ± 4.00 to 14.19 ± 4.71 mm (P = 0.001), which was significant. The clavicular drill hole diameter increased from 5.5 to a mean of 8.00 ± 0.75 mm. General patient satisfaction was excellent.

CONCLUSIONS

There were no significant differences between the two groups. There were no implant related complications in the clavicular wound healing. The results support the notion that good results are achieved by reconstructing both the CC and AC ligaments with a tendon graft.

STUDY REGISTRATION

This clinical trial was registered on Clinicaltrials.gov.

The effect of mandala coloring on anxiety and quality of life of women in the climacteric period: a randomized controlled study

OBJECTIVE

This study was conducted to determine the effect of mandala coloring on anxiety and quality of life of women in the climacteric period.

METHODS

This research was conducted as an experimental study based on a randomized controlled pre-test and post-test model (single-blind). The study was conducted with women in the climacteric period who presented to a training and research hospital in a western city of Turkey between November 1, 2022, and April 28, 2023. Participants were divided into mandala coloring (n=38) and control groups (n=38).

RESULTS

According to the women's socio-demographic and descriptive characteristics, mean age, body mass index, and frequency of menopausal symptoms were similar in both groups. The mean post-test scores of the women in the mandala coloring group on the state-trait anxiety inventory and menopause-specific quality of life questionnaire vasomotor, psychosocial, physical, and sexual subscales (29.71±5.22, 0.86±0.97, 0.53±0.61, 0.79±0.84, and 0.92±1.24, respectively) were lower than the mean post-test scores of the women in the control group on the same scales (41.02±1.20, 1.79±1.76, 1.49±1.39, 1.72±1.38, and 1.95±1.82, respectively) (p=0.000).

CONCLUSION

Mandala coloring reduces menopause-related anxiety levels and improves quality of life effectively.

The effect of photobiomodulation on histamine and Mucuna pruriens-induced pruritus, hyperknesis and alloknesis in healthy volunteers: A double-blind, randomized, sham-controlled study

BACKGROUND

Photobiomodulation, also referred to as Low-Level Light Therapy (LLLT), has emerged as a promising intervention for pruritus, a prevalent and often distressing symptom.

OBJECTIVES

This study investigated the efficacy of low-level light therapy (LLLT) in alleviating pruritus, hyperknesis, and alloknesis induced by histamine and Mucuna pruriens.

METHODS

In a double-blind, randomized, sham-controlled trial with a split-body design, healthy volunteers underwent 6 minutes of LLLT and sham treatments in separate upper back quadrants. The histamine model was applied to the upper quadrants, and Mucuna pruriens to the lower quadrants. Pruritus intensity, alloknesis, hyperknesis, flare area, and skin temperature were measured pre and post treatment.

RESULTS

Seventeen individuals (eight females, nine males) participated in the study. In the histamine model, LLLT notably reduced itch intensity (difference = 13.9 (95% CI: 10.5 - 17.4), p = 0.001), alloknesis (difference = 0.80 (95% CI: 0.58-1.02), p = 0.001), and hyperknesis (difference = 0.48 (95% CI: 0.09-0.86), p = 0.01). Skin temperature changes were not significantly different between the two groups (difference = -2.0 (95% CI: -6.7-2.6), p = 0.37). For the Mucuna pruriens model, no significant differences were observed in any measures, including itch intensity (difference = 0.8 (95% CI: -2.3 - 3.8), p = 0.61) hyperknesis (difference = 0.08 (95% CI: -0.06-0.33), p = 0.16) and alloknesis (difference = 0. 0.09 (95% CI: -0.08-0.256), p = 0.27).

CONCLUSIONS

LLLT effectively reduced histamine-induced pruritus, alloknesis, and hyperknesis; however, LLLT was ineffective against Mucuna pruriens-induced pruritus. Further investigations are required to determine LLLT's effectiveness of LLLT in various pruritus models.

Comparison of the Effects of Adductor Canal and Femoral Nerve Blocks on Postoperative Opioid Consumption and Inflammatory Factor Levels in Elderly Patients After Total Knee Arthroplasty: A Prospective Observational Study

Purpose

Total Knee Arthroplasty (TKA) is a highly invasive procedure causing severe postoperative pain, which hampers early mobility. Effective pain management is crucial for optimal recovery. This study aimed to evaluate how adductor canal block (ACB) and femoral nerve block (FNB) affect opioid use and inflammation factor levels in elderly TKA patients.

Methods

This prospective observational study included 120 patients who received TKA, and divided them into three groups, based on the different nerve block technique: ACB, FNB, and no intervention before general anesthesia (CON). Postoperative opioid consumption, pain assessment, inflammation factor, knee function recovery and other clinical indicators were recorded.

Results

The CON group had significantly higher cumulative sufentanil consumption compared to the ACB and FNB groups at both 12 h and 48h postoperative (P<0.001). Compared with the CON group, the ACB and FNB groups persistently had lower pain scores until 12 h at rest and 24 h during motion after surgery. The ACB group showed significantly lower serum concentrations of C-reactive protein (CRP) and interleukin-6 (IL-6) compared to the CON group at 24 h postoperative (P=0.017, P=0.009), and IL-6 levels remained significantly lower at 72 h postoperative (P=0.005). Both ACB and FNB groups achieved earlier ambulation compared to the CON group (P=0.002). On the first day postoperative, both the ACB and FNB groups showed significantly better knee motion (P<0.001), quadriceps strength (P<0.001), and daily mobilization (P<0.001) compared to the CON group. Additionally, the ACB group exhibited superior quadriceps strength (P<0.001) and daily mobilization (P<0.001) compared to the FNB group.

Conclusion

The ACB and FNB groups exhibited comparable clinical efficacy outcomes in terms of pain scores and opioid consumption. However, the ACB group experienced reduced postoperative inflammation and improved knee recovery, especially in quadriceps strength.

Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN for OMIs 2024

PURPOSE

Although comprehensive and widespread guidelines on how to conduct systematic reviews of outcome measurement instruments (OMIs) exist, for example from the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) initiative, key information is often missing in published reports. This article describes the development of an extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guideline: PRISMA-COSMIN for OMIs 2024.

METHODS

The development process followed the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines and included a literature search, expert consultations, a Delphi study, a hybrid workgroup meeting, pilot testing, and an end-of-project meeting, with integrated patient/public involvement.

RESULTS

From the literature and expert consultation, 49 potentially relevant reporting items were identified. Round 1 of the Delphi study was completed by 103 panelists, whereas round 2 and 3 were completed by 78 panelists. After 3 rounds, agreement (≥ 67%) on inclusion and wording was reached for 44 items. Eleven items without consensus for inclusion and/or wording were discussed at a workgroup meeting attended by 24 participants. Agreement was reached for the inclusion and wording of 10 items, and the deletion of 1 item. Pilot testing with 65 authors of OMI systematic reviews further improved the guideline through minor changes in wording and structure, finalized during the end-of-project meeting. The final checklist to facilitate the reporting of full systematic review reports contains 54 (sub)items addressing the review's title, abstract, plain language summary, open science, introduction, methods, results, and discussion. Thirteen items pertaining to the title and abstract are also included in a separate abstract checklist, guiding authors in reporting for example conference abstracts.

CONCLUSION

PRISMA-COSMIN for OMIs 2024 consists of two checklists (full reports; abstracts), their corresponding explanation and elaboration documents detailing the rationale and examples for each item, and a data flow diagram. PRISMA-COSMIN for OMIs 2024 can improve the reporting of systematic reviews of OMIs, fostering their reproducibility and allowing end-users to appraise the quality of OMIs and select the most appropriate OMI for a specific application. NOTE: In order to encourage its wide dissemination this article is freely accessible on the web sites of the journals: Health and Quality of Life Outcomes; Journal of Clinical Epidemiology; Journal of Patient-Reported Outcomes; Quality of Life Research.

Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN for OMIs 2024

PURPOSE

Although comprehensive and widespread guidelines on how to conduct systematic reviews of outcome measurement instruments (OMIs) exist, for example from the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) initiative, key information is often missing in published reports. This article describes the development of an extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guideline: PRISMA-COSMIN for OMIs 2024.

METHODS

The development process followed the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines and included a literature search, expert consultations, a Delphi study, a hybrid workgroup meeting, pilot testing, and an end-of-project meeting, with integrated patient/public involvement.

RESULTS

From the literature and expert consultation, 49 potentially relevant reporting items were identified. Round 1 of the Delphi study was completed by 103 panelists, whereas round 2 and 3 were completed by 78 panelists. After 3 rounds, agreement (≥67%) on inclusion and wording was reached for 44 items. Eleven items without consensus for inclusion and/or wording were discussed at a workgroup meeting attended by 24 participants. Agreement was reached for the inclusion and wording of 10 items, and the deletion of 1 item. Pilot testing with 65 authors of OMI systematic reviews further improved the guideline through minor changes in wording and structure, finalized during the end-of-project meeting. The final checklist to facilitate the reporting of full systematic review reports contains 54 (sub)items addressing the review's title, abstract, plain language summary, open science, introduction, methods, results, and discussion. Thirteen items pertaining to the title and abstract are also included in a separate abstract checklist, guiding authors in reporting for example conference abstracts.

CONCLUSION

PRISMA-COSMIN for OMIs 2024 consists of two checklists (full reports; abstracts), their corresponding explanation and elaboration documents detailing the rationale and examples for each item, and a data flow diagram. PRISMA-COSMIN for OMIs 2024 can improve the reporting of systematic reviews of OMIs, fostering their reproducibility and allowing end-users to appraise the quality of OMIs and select the most appropriate OMI for a specific application. NOTE: In order to encourage its wide dissemination this article is freely accessible on the web sites of the journals: Health and Quality of Life Outcomes; Journal of Clinical Epidemiology; Journal of Patient-Reported Outcomes; Quality of Life Research.

Doppler ultrasound of umbilical and middle cerebral artery in third trimester small-for-gestational age fetuses to decide on timing of delivery for suspected fetal growth restriction: A cohort with nested RCT (DRIGITAT)

OBJECTIVE

To assess the association of the umbilicocerebral ratio (UCR) with adverse perinatal outcome in late preterm small-for-gestational age (SGA) fetuses and to investigate the effect on perinatal outcomes of immediate delivery.

DESIGN

Multicentre cohort study with nested randomised controlled trial (RCT).

SETTING

Nineteen secondary and tertiary care centres.

POPULATION

Singleton SGA pregnancies (estimated fetal weight [EFW] or fetal abdominal circumference [FAC] <10th centile) from 32 to 36+6 weeks.

METHODS

Women were classified: (1) RCT-eligible: abnormal UCR twice consecutive and EFW below the 3rd centile at/or below 35 weeks or below the 10th centile at 36 weeks; (2) abnormal UCR once or intermittent; (3) never abnormal UCR. Consenting RCT-eligible patients were randomised for immediate delivery from 34 weeks or expectant management until 37 weeks.

MAIN OUTCOME MEASURES

A composite adverse perinatal outcome (CAPO), defined as perinatal death, birth asphyxia or major neonatal morbidity.

RESULTS

The cohort consisted of 690 women. The study was halted prematurely for low RCT-inclusion rates (n = 40). In the RCT-eligible group, gestational age at delivery, birthweight and birthweight multiple of the median (MoM) (0.66, 95% confidence interval [CI] 0.59-0.72) were significantly lower and the CAPO (n = 50, 44%, p < 0.05) was more frequent. Among patients randomised for immediate delivery there was a near-significant lower birthweight (p = 0.05) and higher CAPO (p = 0.07). EFW MoM, pre-eclampsia, gestational hypertension and Doppler classification were independently associated with the CAPO (area under the curve 0.71, 95% CI 0.67-0.76).

CONCLUSIONS

Perinatal risk was effectively identified by low EFW MoM and UCR. Early delivery of SGA fetuses with an abnormal UCR at 34-36 weeks should only be performed in the context of clinical trials.

Adverse event monitoring and reporting in pediatric neuromodulatory studies: A systematic review

Neuromodulatory interventions are relatively novel and approaches to studying harms and tolerability have varied. Using a checklist based on guidelines from Good Clinical Practice and the Harms Extension of the CONSORT (Consolidated Standards of Reporting Trials) Statement, we identified how adverse events are measured, assessed, and reported in studies evaluating neuromodulation for the treatment of mental and neurodevelopmental disorders among children and adolescents. A systematic literature review identified 56 experimental and quasi-experimental studies evaluating transcranial magnetic stimulation (TMS), transcranial alternating (tACS) or direct (tDCS) current stimulation, transcranial pulse stimulation (TPS), and vagus or trigeminal nerve stimulation (VNS or TNS). For 22 studies (39%), the types of adverse events to be monitored were identified, and for 31 studies (55%), methods for collecting adverse event data were described. Methods for assessing adverse events were less commonly described with 23 studies (41%) having details on assessing event severity, and 11 studies (20%) having details on assessing event causality. Among 31 studies with reported results, headache, skin irritation, and general pain or discomfort were the most reported across studies. Seizure, untoward medical occurrences, and intracranial bleeding, edema, or other intracranial pathology were considered serious events, but these events were not reported as occurring in any results-based papers. Taken together, the findings from this review indicate that most studies of pediatric neuromodulatory interventions did not include descriptions of adverse event monitoring and evaluation. Comprehensive event monitoring and reporting across studies can significantly augment the current knowledge base.

Efficacy of a new protocol for the prevention of work-related musculoskeletal disorders in dental hygiene students: A pilot randomized controlled trial

OBJECTIVE

The purpose of this pilot randomized controlled trial (RCT) was to assess the efficacy of a new muscle stretching and strengthening protocol for the prevention of work-related musculoskeletal disorders (WMSD) in dental hygiene students.

METHODS

Students attending the 2nd and 3rd year of a Dental Hygiene Degree Course of a University Hospital were randomly allocated into treatment group (muscle stretching and strengthening sessions) and control group (no treatment). Nordic Musculoskeletal Questionnaire (NMQ), quality of life, the intensity of the pain and the Global Perceived Effect (GPE) Scale were assessed at the baseline (T0), after 4 weeks (T1) and after 16 weeks (T2).

RESULTS

Of 37 subjects screened for eligibility, 28 patients (aged 28.25 ± 8.89 years) were enrolled and divided into treatment and control groups. The NWQ showed significant between-group differences in the following regions from T0 to T2: neck (p = 0.0003), shoulders (p = 0.0057) and lower back (p = 0.0136). In terms of pain, a significant between-group difference was reported from T2 (p < 0.001). The GPE demonstrated that the average satisfaction related to the performed treatment was 1.4 ± 0.63.

CONCLUSION

The present pilot RCT demonstrated the efficacy of stretching associated with muscle strengthening in decreasing the risk of WMSD, especially for the neck, shoulders and lower back. The potential strength of this model is related to the possibility to perform stretching exercises chairside at work during scheduled breaks, in addition to complementary muscle strengthening sessions at home. Future RCTs are necessary to better investigate the role of this protocol for WMSD prevention.

Effect of comprehensive rehabilitation on apnea hypopnea index in patients with obstructive sleep apnea: a protocol for randomized controlled trial

PURPOSE

The aim of this study is to investigate the effect of comprehensive rehabilitation on apnea hypopnea index (AHI) in patients with obstructive sleep apnea (OSA).

METHODS

Patients diagnosed with OSA and meeting the eligibility criteria will be randomly allocated in the groups. The experimental group will receive comprehensive rehabilitation, and the control group will receive myofunctional therapy. CPAP will be continued by all the participants. Both the groups will receive the interventions for 12 weeks. The primary outcome measures are AHI and Epworth Sleepiness Scale (ESS), and secondary outcomes are Pittsburg Sleep Quality Index (PSQI), Oxygen Desaturation Index (ODI), Snoring Index (SI), Manual Assessment of Respiratory Motion (MARM), Breath Hold Test (BHT), and Self Evaluation of Breathing Questionnaire (SEBQ). The outcomes will be assessed at baseline and at the end of 12 weeks. A follow-up will be taken at the end of 24 weeks. Power analysis suggests that enrollment of 118 patients will required. Repeated measures ANOVA will be used to analyze the effect of the intervention.

CONCLUSION

By performing this research, we may develop insights on a novel comprehensive approach for treatment of patients with OSA.

TRIAL REGISTRATION

CTRI/2023/10/058486.

Consensus for experimental design in electromyography (CEDE) project: Checklist for reporting and critically appraising studies using EMG (CEDE-Check)

The diversity in electromyography (EMG) techniques and their reporting present significant challenges across multiple disciplines in research and clinical practice, where EMG is commonly used. To address these challenges and augment the reproducibility and interpretation of studies using EMG, the Consensus for Experimental Design in Electromyography (CEDE) project has developed a checklist (CEDE-Check) to assist researchers to thoroughly report their EMG methodologies. Development involved a multi-stage Delphi process with seventeen EMG experts from various disciplines. After two rounds, consensus was achieved. The final CEDE-Check consists of forty items that address four critical areas that demand precise reporting when EMG is employed: the task investigated, electrode placement, recording electrode characteristics, and acquisition and pre-processing of EMG signals. This checklist aims to guide researchers to accurately report and critically appraise EMG studies, thereby promoting a standardised critical evaluation, and greater scientific rigor in research that uses EMG signals. This approach not only aims to facilitate interpretation of study results and comparisons between studies, but it is also expected to contribute to advancing research quality and facilitate clinical and other practical applications of knowledge generated through the use of EMG.