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Natarajan P, Menounos S, Harris L, Monuja M, Gorelik A, Karjalainen T, Buchbinder R, Harris IA, Naylor JM, Adie S. Participant recruitment and attrition in surgical randomised trials with placebo controls versus non-operative controls: a meta-epidemiological study and meta-analysis. BMJ Open 2024; 14:e080258. [PMID: 38637129 PMCID: PMC11029374 DOI: 10.1136/bmjopen-2023-080258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/22/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVE To compare differences in recruitment and attrition between placebo control randomised trials of surgery, and trials of the same surgical interventions and conditions that used non-operative (non-placebo) controls. DESIGN Meta-epidemiological study. DATA SOURCES Randomised controlled trials were identified from an electronic search of MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from their inception date to 21 November 2018. STUDY SELECTION Placebo control trials evaluating efficacy of any surgical intervention and non-operative control trials of the same surgical intervention were included in this study. 25 730 records were retrieved from our systemic search, identifying 61 placebo control and 38 non-operative control trials for inclusion in analysis. OUTCOME MEASURES Primary outcome measures were recruitment and attrition. These were assessed in terms of recruitment rate (number of participants enrolled, as a proportion of those eligible) and overall attrition rate (composite of dropout, loss to follow-up and cross-overs, expressed as proportion of total sample size). Secondary outcome measures included participant cross-over rate, dropout and loss to follow-up. RESULTS Unadjusted pooled recruitment and attrition rates were similar between placebo and non-operative control trials. Study characteristics were not significantly different apart from time to primary timepoint which was shorter in studies with placebo controls (365 vs 274 days, p=0.006). After adjusting for covariates (follow-up duration and number of timepoints), the attrition rate of placebo control trials was almost twice as high compared with non-operative controlled-trials (incident rate ratio (IRR) (95% CI) 1.8 (1.1 to 3.0), p=0.032). The incorporation of one additional follow-up timepoint (regardless of follow-up duration) was associated with reduced attrition in placebo control surgical trials (IRR (95% CI) 0.64 (0.52 to 0.79), p<0.001). CONCLUSIONS Placebo control trials of surgery have similar recruitment issues but higher attrition compared with non-operative (non-placebo) control trials. Study design should incorporate strategies such as increased timepoints for given follow-up duration to mitigate losses to follow-up and dropout. PROSPERO REGISTRATION NUMBER CRD42019117364.
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Affiliation(s)
- Pragadesh Natarajan
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Spiro Menounos
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Laura Harris
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| | - Masiath Monuja
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Teemu Karjalainen
- Department of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Justine M Naylor
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Sam Adie
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
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Kanthasamy V, Schilling R, Zongo O, Khan K, Earley M, Monk V, Hunter R, Mangiafico V, Ang R, Creta A, Aluwhalia N, Honarbakhsh S, Dhinoja M, Gupta D, Finlay M. Feasibility of double-blinded, placebo-controlled interventional study for assessing catheter ablation efficacy in persistent atrial fibrillation: Insights from the ORBITA AF feasibility study. Am Heart J 2024; 269:56-71. [PMID: 38109985 DOI: 10.1016/j.ahj.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND To date, there are no randomized, double-blinded clinical trials comparing catheter ablation to DC cardioversion (DCCV) with medical therapy in patients with persistent atrial fibrillation (PersAF). Conducting a large-scale trial to address this question presents considerable challenges, including recruitment, blinding, and implementation. We conducted a pilot study to evaluate the feasibility of conducting a definitive placebo-controlled trial. METHODS This prospective trial was carried out at Barts Heart Centre, United Kingdom, employing a randomized, double-blinded, placebo-controlled design. Twenty patients with PersAF (duration <2 years) were recruited, representing 10% of the proposed larger trial as determined by a power calculation. The patients were randomized in a 1:1 ratio to receive either PVI ± DCCV (PVI group) or DCCV + Placebo (DCCV group). The primary endpoint of this feasibility study was to evaluate patient blinding. Patients remained unaware of their treatment allocation until end of study. RESULTS During the study, 35% of patients experienced recurrence of PersAF prior to completion of 12 months follow-up. Blinding was successfully maintained amongst both patients and medical staff. The DCCV group had a trend to higher recurrence and repeat procedure rate compared to the PVI group (recurrence of PersAF 60% vs 30%; p = .07 and repeat procedure 70% vs 40%; p = .4). The quality of life experienced by individuals in the PVI group showed improvement, as evidenced by enhanced scores on the AF specific questionnaire (AF PROMS) (3 [±4] vs 21 [±8]) and SF-12 mental-component raw score (51.4 [±7] vs 43.24 [±15]) in patients who maintained sinus rhythm at 12 months. CONCLUSION This feasibility study establishes the potential for conducting a blinded, placebo-controlled trial to evaluate the efficacy of PVI versus DCCV in patients with PersAF.
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Affiliation(s)
- Vijayabharathy Kanthasamy
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Richard Schilling
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Olivier Zongo
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Kamran Khan
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mark Earley
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Vivienne Monk
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Ross Hunter
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Valentina Mangiafico
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Richard Ang
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Antonio Creta
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Nikhil Aluwhalia
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Shohreh Honarbakhsh
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mehul Dhinoja
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
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Schilling C, Tew M, Bunzli S, Shadbolt C, Lohmander LS, Balogh ZJ, Paolucci F, Choong PF, Dowsey MM, Clarke P. An Economic Model for Estimating Trial Costs with an Application to Placebo Surgery Trials. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:263-273. [PMID: 36575335 PMCID: PMC9931787 DOI: 10.1007/s40258-022-00775-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Waste in clinical trials remains rife. We developed an economic model to predict the cost of trials based on input costs, duration, power, number of sites, recruitment eligibility and consenting rates. METHODS We parameterised the model for three proxy placebo-controlled surgical trials using data from a systematic review, a bespoke cost survey, and from the literature. We used the model to compare target and actual trial performance for (i) a trial that was completed on time but with more sites, (ii) a trial that completed after a time extension, and (iii) an incomplete trial. RESULTS Successful trials more accurately anticipated the true recruitment rate that they achieved and those that overestimated this were most likely to fail. The costs of overestimating recruitment rates were dramatic: all proxy trials had significantly higher costs than planned, with additional funding of at least AUD$600,000 (50% above budget) required for trials that completed after adding more sites or more time, and over AUD$2 million (260% above budget) for incomplete trials. CONCLUSIONS This model shows the trade-offs between time and cost, or both, when recruitment is lower than anticipated. Greater consideration is needed to improve trial planning, reviewing, and funding of these trials to avoid costly overruns and incomplete trials.
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Affiliation(s)
- Chris Schilling
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Michelle Tew
- Melbourne School of Population and Global Health, Centre for Health Policy, University of Melbourne, Melbourne, Australia
| | - Samantha Bunzli
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Cade Shadbolt
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - L. Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, University of Lund, Lund, Sweden
| | - Zsolt J. Balogh
- School of Medicine and Public Health, Department of Traumatology, John Hunter Hospital, The University of Newcastle, Newcastle, Australia
| | - Francesco Paolucci
- College of Human and Social Futures, The Newcastle Business School, University of Newcastle, Newcastle, Australia
- Schools of Economics and Management, University of Bologna, Bologna, Italy
| | - Peter F. Choong
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Department of Orthopaedics, St. Vincent’s Hospital, Melbourne, Australia
| | - Michelle M. Dowsey
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Department of Orthopaedics, St. Vincent’s Hospital, Melbourne, Australia
| | - Philip Clarke
- Melbourne School of Population and Global Health, Centre for Health Policy, University of Melbourne, Melbourne, Australia
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Nugent M, Bryant V, Butcher C, Fisher H, Gill S, Goranova R, Hiu S, Lindley L, O'Hara J, Oluboyede Y, Patterson J, Rapley T, Robinson T, Rousseau N, Ryan V, Shanmugasundaram R, Sharp L, Smith Whelan R, Stocken DD, Ternent L, Wilson J, Walker J. Photobiomodulation in the management of oral mucositis for adult head and neck cancer patients receiving irradiation: the LiTEFORM RCT. Health Technol Assess 2022; 26:1-172. [PMID: 36484364 PMCID: PMC9761526 DOI: 10.3310/uwnb3375] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Oral mucositis is a debilitating and painful complication of head and neck cancer irradiation that is characterised by inflammation of the mucous membranes, erythema and ulceration. Oral mucositis affects 6000 head and neck cancer patients per year in England and Wales. Current treatments have not proven to be effective. International studies suggest that low-level laser therapy may be an effective treatment. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of low-level laser therapy in the management of oral mucositis in head and neck cancer irradiation. To identify barriers to and facilitators of implementing low-level laser therapy in routine care. DESIGN Placebo-controlled, individually randomised, multicentre Phase III superiority trial, with an internal pilot and health economic and qualitative process evaluations. The participants, outcome assessors and therapists were blinded. SETTING Nine NHS head and neck cancer sites in England and Wales. PARTICIPANTS A total of 87 out of 380 participants were recruited who were aged ≥ 18 years and were undergoing head and neck cancer irradiation with ≥ 60 Gy. INTERVENTION Random allocation (1 : 1 ratio) to either low-level laser therapy or sham low-level laser therapy three times per week for the duration of irradiation. The diode laser had the following specifications: wavelength 660 nm, power output 75 mW, beam area 1.5 cm2, irradiance 50 mW/cm2, exposure time 60 seconds and fluence 3 J/cm2. There were 20-30 spots per session. Sham low-level laser therapy was delivered in an identical manner. MAIN OUTCOME MEASURE The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks following the start of irradiation. Higher scores indicate a worse outcome. RESULTS A total of 231 patients were screened and, of these, 87 were randomised (low-level laser therapy arm, n = 44; sham arm, n = 43). The mean age was 59.4 years (standard deviation 8.8 years) and 69 participants (79%) were male. The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks was 33.2 (standard deviation 10) in the low-level laser therapy arm and 27.4 (standard deviation 13.8) in the sham arm. LIMITATIONS The trial lacked statistical power because it did not meet the recruitment target. Staff and patients willingly participated in the trial and worked hard to make the LiTEFORM trial succeed. However, the task of introducing, embedding and sustaining new low-level laser therapy services into a complex care pathway proved challenging. Sites could deliver low-level laser therapy to only a small number of patients at a time. The administration of low-level laser therapy was viewed as straightforward, but also time-consuming and sometimes uncomfortable for both patients and staff, particularly those staff who were not used to working in a patient's mouth. CONCLUSIONS This trial had a robust design but lacked power to be definitive. Low-level laser therapy is relatively inexpensive. In contrast with previous trials, some patients found low-level laser therapy sessions to be difficult. The duration of low-level laser therapy sessions is, therefore, an important consideration. Clinicians experienced in oral cavity work most readily adapt to delivering low-level laser therapy, although other allied health professionals can be trained. Blinding the clinicians delivering low-level laser therapy is feasible. There are important human resource, real estate and logistical considerations for those setting up low-level laser therapy services. FUTURE WORK Further well-designed randomised controlled trials investigating low-level laser therapy in head and neck cancer irradiation are needed, with similar powered recruitment targets but addressing the recruitment challenges and logistical findings from this research. TRIAL REGISTRATION This trial is registered as ISRCTN14224600. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 46. See the NIHR Journals Library website for further project information.
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Lie MLS, McParlin C, McColl E, Graham RH, Robson SC. Emesis in pregnancy - a qualitative study on trial recruitment failure from the EMPOWER internal pilot. Pilot Feasibility Stud 2022; 8:146. [PMID: 35836285 PMCID: PMC9281005 DOI: 10.1186/s40814-022-01093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As part of the internal pilot of the EMPOWER trial investigating the second-line antiemetic therapies in severe emesis in pregnancy ( https://www.isrctn.com/ISRCTN16924692 ), a qualitative study of women's views was carried out, to improve our understanding of why women did, or did not, consent to participation in the trial. Interviews were also conducted with site research staff, to broaden our analysis and explore other factors affecting recruitment. METHODS The sample comprised women who accepted or declined trial participation (n=21) and site research staff (n=22). A structured topic guide was used, in four email interviews and 17 telephone interviews with women, and semi-structured telephone interviews were carried out with staff. Of the women interviewed, seven had declined trial participation, and of the staff interviewed, 16 were research midwives/research nurses and six were principal investigators. All transcripts were checked for accuracy, anonymised and entered into NVIVO12 for indexing and retrieval. Data was analysed using a reflexive thematic analytic approach. In total, 72 codes were generated from the thematic analysis, and 36 from each sample group. RESULTS Three key themes based on all the interviews were (a) the diversity of recruitment pathways and boundaries of care, (b) the impact of trial complexity on recruitment and staff morale and (c) the ethics of caring for a patient with emesis. Ethical issues discussed included the use of double dummy and time to treat, particularly those suffering severely from the effects of nausea and vomiting. To illustrate these themes, staff perspectives are given more prominence. CONCLUSIONS The main reason the trial was stopped related to the high proportion of women ineligible for recruitment due to prior treatment with study drug(s) because of unanticipated changes in clinical practice. The qualitative results also demonstrate the impact of the trial on women and staff and highlight how the diversity of referral pathways, boundaries of care and the complexity of the trial and protocol resulted in additional barriers to successful trial recruitment. Qualitative work in pilot and feasibility studies of a clinical trial is recommended, to evaluate whether recruitment strategies remain viable in unanticipated contexts. TRIAL REGISTRATION Trial registration number ISRCTN16924692 . Date: 08/01/2018.
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Willingness to participate in a hypothetical orthopaedic diagnostic and invasive surgical trial. Injury 2022; 53:1966-1971. [PMID: 35260247 DOI: 10.1016/j.injury.2022.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate patient preferences and the determinants of participation willingness in orthopaedic diagnostic or invasive surgical randomized controlled trials. METHODS This observational study included one hundred patients visiting an orthopaedic clinic. The patients answered if they were willing to participate in a hypothetical invasive and diagnostic trial among patients with a distal radius fracture. RESULTS We found no difference in participation willingness in either the invasive surgical (66/100) or the diagnostic trial (68/100, p = 0.76). Willingness to participate was not associated with age, gender, country of origin, level of education, marital status, or distance of home from the hospital with the confidence interval for all odds ratios including the value 1. Patients who expressed willingness to participate do so because they wanted to contribute to science; patients who declined to participate wanted to speak with a doctor and to be better informed. CONCLUSION This study showed a high rate of willingness to participate in orthopaedic surgical invasive trials and in diagnostic trials. Nevertheless, to ensure participation, it is recommended to put emphasis on the contribution to science and to give adequate information about the trial including the opportunity to talk to a doctor.
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Hinwood M, Wall L, Lang D, Balogh ZJ, Smith A, Dowsey M, Clarke P, Choong P, Bunzli S, Paolucci F. Patient and clinician characteristics and preferences for increasing participation in placebo surgery trials: a scoping review of attributes to inform a discrete choice experiment. Trials 2022; 23:296. [PMID: 35413876 PMCID: PMC9006556 DOI: 10.1186/s13063-022-06277-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Orthopaedic surgeries include some of the highest volume surgical interventions globally; however, studies have shown that a significant proportion of patients report no clinically meaningful improvement in pain or function after certain procedures. As a result, there is increasing interest in conducting randomised placebo-controlled trials in orthopaedic surgery. However, these frequently fail to reach recruitment targets suggesting a need to improve trial design to encourage participation. The objective of this study was to systematically scope the available evidence on patient and clinician values and preferences which may influence the decision to participate in placebo surgery trial. METHODS A systematic review was conducted via a literature search in the MEDLINE, Embase, PsycInfo, CINAHL, and EconLit databases as of 19 July 2021, for studies of any design (except commentaries or opinion pieces) based on two key concepts: patient and clinician characteristics, values and preferences, and placebo surgery trials. RESULTS Of 3424 initial articles, we retained 18 eligible studies. Characteristics, preferences, values, and attitudes of patients (including levels of pain/function, risk/benefit perception, and altruism) and of clinicians (including concerns regarding patient deception associated with placebo, and experience/training in research) influenced their decisions to participate in placebo-controlled trials. Furthermore, some aspects of trial design, including randomisation procedures, availability of the procedure outside of the trial, and the information and consent procedures used, also influenced decisions to participate. CONCLUSION Participant recruitment is a significant challenge in placebo surgery trials, and individual decisions to participate appear to be sensitive to preferences around treatment. Understanding and quantifying the role patient and clinician preferences may play in surgical trials may contribute to the optimisation of the design and implementation of clinical trials in surgery.
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Affiliation(s)
- Madeleine Hinwood
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Laura Wall
- Newcastle Business School, University of Newcastle, Newcastle, Australia
| | - Danielle Lang
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, Australia
| | - Angela Smith
- Hunter New England Local Health District, Newcastle, Australia
| | - Michelle Dowsey
- Department of Surgery, St Vincent’s Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Phillip Clarke
- School of Population and Global Health, University of Melbourne, Australia, Parkville, Australia
- Health Economics Research Centre, University of Oxford, Oxford, England
| | - Peter Choong
- Department of Surgery, St Vincent’s Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Samantha Bunzli
- Department of Surgery, St Vincent’s Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Francesco Paolucci
- Newcastle Business School, University of Newcastle, Newcastle, Australia
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O'Connor D, Johnston RV, Brignardello-Petersen R, Poolman RW, Cyril S, Vandvik PO, Buchbinder R. Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears). Cochrane Database Syst Rev 2022; 3:CD014328. [PMID: 35238404 PMCID: PMC8892839 DOI: 10.1002/14651858.cd014328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Arthroscopic knee surgery remains a common treatment for symptomatic knee osteoarthritis, including for degenerative meniscal tears, despite guidelines strongly recommending against its use. This Cochrane Review is an update of a non-Cochrane systematic review published in 2017. OBJECTIVES To assess the benefits and harms of arthroscopic surgery, including debridement, partial menisectomy or both, compared with placebo surgery or non-surgical treatment in people with degenerative knee disease (osteoarthritis, degenerative meniscal tears, or both). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trials registers up to 16 April 2021, unrestricted by language. SELECTION CRITERIA We included randomised controlled trials (RCTs), or trials using quasi-randomised methods of participant allocation, comparing arthroscopic surgery with placebo surgery or non-surgical interventions (e.g. exercise, injections, non-arthroscopic lavage/irrigation, drug therapy, and supplements and complementary therapies) in people with symptomatic degenerative knee disease (osteoarthritis or degenerative meniscal tears or both). Major outcomes were pain, function, participant-reported treatment success, knee-specific quality of life, serious adverse events, total adverse events and knee surgery (replacement or osteotomy). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was arthroscopic surgery compared to placebo surgery for outcomes that measured benefits of surgery, but we combined data from all control groups to assess harms and knee surgery (replacement or osteotomy). MAIN RESULTS Sixteen trials (2105 participants) met our inclusion criteria. The average age of participants ranged from 46 to 65 years, and 56% of participants were women. Four trials (380 participants) compared arthroscopic surgery to placebo surgery. For the remaining trials, arthroscopic surgery was compared to exercise (eight trials, 1371 participants), a single intra-articular glucocorticoid injection (one trial, 120 participants), non-arthroscopic lavage (one trial, 34 participants), non-steroidal anti-inflammatory drugs (one trial, 80 participants) and weekly hyaluronic acid injections for five weeks (one trial, 120 participants). The majority of trials without a placebo control were susceptible to bias: in particular, selection (56%), performance (75%), detection (75%), attrition (44%) and selective reporting (75%) biases. The placebo-controlled trials were less susceptible to bias and none were at risk of performance or detection bias. Here we limit reporting to the main comparison, arthroscopic surgery versus placebo surgery. High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates there is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery. Mean post-operative pain in the placebo group was 40.1 points on a 0 to 100 scale (where lower score indicates less pain) compared to 35.5 points in the arthroscopic surgery group, a difference of 4.6 points better (95% confidence interval (CI) 0.02 better to 9 better; I2 = 0%; 4 trials, 309 participants). Mean post-operative function in the placebo group was 75.9 points on a 0 to 100 rating scale (where higher score indicates better function) compared to 76 points in the arthroscopic surgery group, a difference of 0.1 points better (95% CI 3.2 worse to 3.4 better; I2 = 0%; 3 trials, 302 participants). Mean post-operative knee-specific health-related quality of life in the placebo group was 69.7 points on a 0 to 100 rating scale (where higher score indicates better quality of life) compared with 75.3 points in the arthroscopic surgery group, a difference of 5.6 points better (95% CI 0.36 better to 10.68 better; I2 = 0%; 2 trials, 188 participants). We downgraded this evidence to moderate certainty as the 95% confidence interval does not rule in or rule out a clinically important change. After surgery, 74 out of 100 people reported treatment success with placebo and 82 out of 100 people reported treatment success with arthroscopic surgery at up to five years (risk ratio (RR) 1.11, 95% CI 0.66 to 1.86; I2 = 53%; 3 trials, 189 participants). We downgraded this evidence to low certainty due to serious indirectness (diversity in definition and timing of outcome measurement) and serious imprecision (small number of events). We are less certain if the risk of serious or total adverse events increased with arthroscopic surgery compared to placebo or non-surgical interventions. Serious adverse events were reported in 6 out of 100 people in the control groups and 8 out of 100 people in the arthroscopy groups from eight trials (RR 1.35, 95% CI 0.64 to 2.83; I2 = 47%; 8 trials, 1206 participants). Fifteen out of 100 people reported adverse events with control interventions, and 17 out of 100 people with surgery at up to five years (RR 1.15, 95% CI 0.78 to 1.70; I2 = 48%; 9 trials, 1326 participants). The certainty of the evidence was low, downgraded twice due to serious imprecision (small number of events) and possible reporting bias (incomplete reporting of outcome across studies). Serious adverse events included death, pulmonary embolism, acute myocardial infarction, deep vein thrombosis and deep infection. Subsequent knee surgery (replacement or high tibial osteotomy) was reported in 2 out of 100 people in the control groups and 4 out of 100 people in the arthroscopy surgery groups at up to five years in four trials (RR 2.63, 95% CI 0.94 to 7.34; I2 = 11%; 4 trials, 864 participants). The certainty of the evidence was low, downgraded twice due to the small number of events. AUTHORS' CONCLUSIONS Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.
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Affiliation(s)
- Denise O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Sheila Cyril
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
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9
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Bunzli S, Nelson E, Wall L, Schilling C, Lohmander LS, Balogh ZJ, Tran P, Paolucci F, Clarke P, Choong PFM, Dowsey MM. Factors Underlying Patient and Surgeon Willingness to Participate in a Placebo Surgery Controlled trial: A Qualitative Investigation. ANNALS OF SURGERY OPEN 2021; 2:e104. [PMID: 37637882 PMCID: PMC10455200 DOI: 10.1097/as9.0000000000000104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/26/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate the factors underlying willingness to participate in a hypothetical trial among patients and surgeons, to inform the design of future placebo surgery controlled trials. Background Placebo surgery controlled trials are the gold standard for testing the efficacy of surgical procedures. However, these trials commonly fail to meet the target sample size and terminate underpowered. Methods From October 2019 to July 2020, eligible patients were identified from the orthopedic waiting list at a single tertiary hospital and surgeons were identified from orthopedic clinics at three tertiary hospitals in Australia. Qualitative interviews explored factors underlying willingness to participate in a hypothetical trial, including understanding of trial concepts; attitudes; and trial design preferences. Data collection and analysis were conducted in parallel. Recruitment ceased when no new concepts emerged. Interview data were analyzed using reflexive thematic analysis. Results The majority of surgeons and only a few patients indicated a willingness to participate in a placebo surgery controlled trial. Factors underlying willingness were captured in four themes: (1) Understanding and attitudes toward placebo; (2) Attitudes towards randomization/perception of equipoise; (3) Perception of risk; and (4) Ethical concerns. Conclusions To optimize recruitment in the future, trialists may consider embedding strategies into the recruitment process that validate patients' symptoms, encourage an altruistic mindset, address surgeon biases, and involve surgeons in explaining trial concepts to patients. Trialists may also consider designing three arm trials that meet surgeons' preferences for a "low" and "high" fidelity placebo.
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Affiliation(s)
- Samantha Bunzli
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Elizabeth Nelson
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Laura Wall
- Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, NSW, Australia
| | - Chris Schilling
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - L. Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, University of Lund, Lund, Sweden
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Phong Tran
- Western Health, Footscray Hospital, Melbourne, VIC, Australia
| | - Francesco Paolucci
- Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, NSW, Australia
| | - Philip Clarke
- Health Economics Research Centre, Oxford University, Oxford, United Kingdom
| | - Peter F. M. Choong
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle M. Dowsey
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
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10
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Uhe T, Beimel S, Langhammer R, Stegmann T, Hindricks G, Laufs U, Dagres N, Wachter R. Patients' attitude towards a sham-controlled trial on pulmonary vein isolation in atrial fibrillation. Clin Res Cardiol 2021; 111:114-123. [PMID: 34709451 PMCID: PMC8766391 DOI: 10.1007/s00392-021-01959-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/19/2021] [Indexed: 01/09/2023]
Abstract
Background The interpretation of recent trials on pulmonary vein ablation (PVI) for the treatment of atrial fibrillation (AF) is hampered by the lack of blinding and sham controls. The feasibility of a sham-controlled trial has been questioned. We aimed to assess the attitude of potential participants regarding a sham-controlled trial in a common AF-patient population planned for PVI. Methods Patients in two tertiary care centres planned for PVI were asked for their current AF symptoms using the Atrial Fibrillation Effect on QualiTy of Life (AFEQT) questionnaire 1 day before catheter ablation. Subsequently, the study design of a hypothetical sham-controlled PVI-study was introduced, and patients were asked for their agreement in participation. Telephone follow-up of the AFEQT questionnaire was conducted 3 months after PVI. Results One hundred and ninety-six patients (mean age 64 ± 11 years, 63% male) were included. Seventy-nine (40%) patients expressed their agreement to participate in the hypothetical sham-controlled trial. An additional 7% agreed to participate if a cross-over option after three months was offered. Agreement rate was similar in patients with first and Redo-PVI and minimal, moderate or severe symptoms. Mean overall AFEQT at baseline was 55 ± 19 and improved by 25 ± 20 points after 3 months (p < 0.001 versus baseline). Conclusion With a participation rate of 40% in potential study participants, a sham-controlled trial for pulmonary vein isolation seems feasible. Patient-reported symptom relief after pulmonary vein isolation is in accordance with previous randomized open studies. The benefit of PVI should be rigorously evaluated in a sham-controlled trial. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01959-z.
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Affiliation(s)
- Tobias Uhe
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04317, Leipzig, Germany.
| | - Samira Beimel
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04317, Leipzig, Germany.,Abteilung für Rhythmologie, Herzzentrum Leipzig, Leipzig, Germany
| | - Romy Langhammer
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04317, Leipzig, Germany
| | - Tina Stegmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04317, Leipzig, Germany
| | | | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04317, Leipzig, Germany
| | - Nikolaos Dagres
- Abteilung für Rhythmologie, Herzzentrum Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04317, Leipzig, Germany
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11
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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12
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Mulcahy MJ, Elalingam T, Jang K, D'Souza M, Tait M. Bilateral cervical plexus block for anterior cervical spine surgery: study protocol for a randomised placebo-controlled trial. Trials 2021; 22:424. [PMID: 34187541 PMCID: PMC8244165 DOI: 10.1186/s13063-021-05377-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 06/15/2021] [Indexed: 11/28/2022] Open
Abstract
Background There has been increasing focus to improve the quality of recovery following anterior cervical spine surgery (ACSS). Postoperative pain and nausea are the most common reasons for prolonged hospital stay and readmission after ACSS. Superficial cervical plexus block (SCPB) provides site-specific analgesia with minimal side effects, thereby improving the quality of recovery. The aim of our study was to investigate the effect bilateral cervical plexus block has on postoperative recovery in patients undergoing ACSS. Methods The study is a pragmatic, multi-centre, blinded, parallel-group, randomised placebo-controlled trial. 136 eligible patients (68 in each group) undergoing ACSS will be included. Patients randomised to the intervention group will have a SCPB administered under ultrasound guidance with a local anaesthetic solution (0.2% ropivacaine, 15mL); patients randomised to the placebo group will be injected in an identical manner with a saline solution. The primary outcome is the 40-item quality of recovery questionnaire score at 24 h after surgery. In addition, comparisons between groups will be made for a 24-h opioid usage and length of hospital stay. Neck pain intensity will be quantified using the numeric rating scale at 1, 3, 6 and at 24 h postoperatively. Incidence of nausea, vomiting, dysphagia or hoarseness in the first 24 h after surgery will also be measured. Discussion By conducting a blinded placebo trial, we aim to control for the bias inherently associated with a tangible medical intervention and show the true treatment effect of SCPB in ACSS. A statistically significant result will indicate an overall improved quality of recovery for patients; alternatively, if no benefit is shown, this trial will provide evidence that this intervention is unnecessary. Trial registration ClinicalTrials.gov ACTRN12619000028101. Prospectively registered on 11 January 2019 with Australia New Zealand Clinical Trials Registry
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Affiliation(s)
- Michael J Mulcahy
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia. .,Macquarie Neurosurgery, Suite 201, 2 Technology Place, Sydney, Australia.
| | - Thananchayan Elalingam
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Kevin Jang
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia
| | - Mario D'Souza
- Central Clinical School, University of Sydney, Sydney, Australia
| | - Matthew Tait
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia.,Macquarie Neurosurgery, Suite 201, 2 Technology Place, Sydney, Australia
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13
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Hare KB, Brand E, Bloch T. Highly impacted bone allograft may allow immediate weight bearing in tibial plateau fractures: A case report. Trauma Case Rep 2020; 29:100331. [PMID: 32715076 PMCID: PMC7378690 DOI: 10.1016/j.tcr.2020.100331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2020] [Indexed: 10/25/2022] Open
Abstract
Introduction Proximal tibial fractures are common with an incidence of 10.2/100.000. Those displaced and involving the articular surface will often require surgical treatment. However, no consensus exists on whether to allow the patient early weight bearing or not. We developed a technique using structural bone chips, highly impacted under the articular surface, to permit immediate weight bearing after surgery. Patient The patient was a 44-year old male who suffered a lateral tibial plateau fracture (AO type 41B2). Intervention We used an anterolateral approach with an S-shaped incision. A small window in the tibia was made using an awl, and the articular surface was reduced under radiographic imaging. The bone allograft was prepared by splitting the frozen femoral head in quarters and then taking large pieces of bone with a bone rongeur forceps avoiding the cartilage. The large pieces of bone were gathered in a small tray and thereafter compressed into the drill guide insert. The drill guide filled with bone graft was then inserted into the tibia window and directed in the appropriate position guided by radiography. Hereafter, the bone graft was impacted under the articular surface with force using the appropriate trocar and a hammer, and the fracture was finally reduced. Finally, the fracture was fixated utilizing an angular stable plate. Outcome The patient was followed up one year postoperatively and allowed immediate weight bearing after surgery. No subsequent articular collapse occurred. Discussion In this case, we present a proximal tibial fracture with articular depression, which was surgically treated with a highly impacted bone allograft of large pieces and a locking plate. The patient was allowed immediate weight bearing and no subsequent articular collapse occurred.
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Affiliation(s)
- Kristoffer B Hare
- Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Eske Brand
- Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
| | - Thomas Bloch
- Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
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14
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Bain MA, Koullias GJ, Morse K, Wendling S, Sabolinski ML. Type I collagen matrix plus polyhexamethylene biguanide antimicrobial for the treatment of cutaneous wounds. J Comp Eff Res 2020; 9:691-703. [PMID: 32476449 DOI: 10.2217/cer-2020-0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Aim: Determine the effectiveness of purified native type I collagen matrix plus polyhexamethylene biguanide antimicrobial (PCMP) on cutaneous wounds. Materials & methods: A prospective cohort study of 307 patients (67 venous leg ulcers, 62 diabetic foot ulcers, 45 pressure ulcers, 54 post-surgical wounds and 79 other wounds) was conducted. Results: Cox wound closure for PCMP was 73% at week 32. The median time to wound closure was 17 weeks (Kaplan-Meier). The incidence of PCMP-treated wounds showing >60% reductions in areas, depths and volumes were 81, 71 and 85%, respectively. Conclusion: PCMP demonstrated clinically meaningful benefits to patients with various types of cutaneous wounds. Clinical Trial registration number: NCT03286452.
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Affiliation(s)
- Michael A Bain
- Department of Plastic Surgery, Hoag Hospital, Newport Beach & Irvine, CA 92663, USA
| | - George J Koullias
- Department of Surgery, Stony Brook School of Medicine, Stony Brook, NY 11794, USA
| | - Keith Morse
- Yavapai Regional Medical Center, Prescott, AZ 86301, USA
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15
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Gorayeb RP, Forjaz MJ, Ferreira AG, Ferreira JJ. Use of Sham Interventions in Randomized Controlled Trials in Neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2020; 81:456-462. [PMID: 32438420 DOI: 10.1055/s-0040-1709161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of sham interventions in randomized controlled trials (RCTs) is essential to minimize bias. However, their use in surgical RCTs is rare and subject to ethical concerns. To date, no studies have looked at the use of sham interventions in RCTs in neurosurgery. METHODS This study evaluated the frequency, type, and indication of sham interventions in RCTs in neurosurgery. RCTs using sham interventions were also characterized in terms of design and risk of bias. RESULTS From a total of 1,102 identified RCTs in neurosurgery, 82 (7.4%) used sham interventions. The most common indication for the RCT was the treatment of pain (67.1%), followed by the treatment of movement disorders and other clinical problems (18.3%) and brain injuries (12.2%). The most used sham interventions were saline injections into spinal structures (31.7%) and peripheral nerves (10.9%), followed by sham interventions in cranial surgery (26.8%), and spine surgery (15.8%). Insertion of probes or catheters for a sham lesions was performed in 14.6%.In terms of methodology, most RCTs using sham interventions were double blinded (76.5%), 9.9% were single blinded, and 13.6% did not report the type of blinding. CONCLUSION Sham-controlled RCTs in neurosurgery are feasible. Most aim to minimize bias and to evaluate the efficacy of pain management methods, especially in spinal disorders. The greatest proportion of sham-controlled RCTs involves different types of substance administration routes, with sham surgery the less commonly performed.
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Affiliation(s)
- Rodrigo Panico Gorayeb
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Maria João Forjaz
- National School of Public Health, Institute of Health Carlos III and REDISSEC, Madrid, Spain
| | | | - Joaquim José Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal.,Instituto de Medicina Molecular, Lisbon, Portugal
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16
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Wall L, Hinwood M, Lang D, Smith A, Bunzli S, Clarke P, Choong PFM, Dowsey MM, Paolucci F. Attitudes of patients and surgeons towards sham surgery trials: a protocol for a scoping review of attributes to inform a discrete choice experiment. BMJ Open 2020; 10:e035870. [PMID: 32161162 PMCID: PMC7066609 DOI: 10.1136/bmjopen-2019-035870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In order to properly evaluate the efficacy of orthopaedic procedures, rigorous, randomised controlled sham surgery trial designs are necessary. However, randomised controlled trials (RCTs) for surgery involving a placebo are ethically debated and difficult to conduct with many failing to reach their desired sample size and power. A review of the literature on barriers and enablers to recruitment, and patient and surgeon attitudes and preferences towards sham surgery trials, will help to determine the characteristics necessary for successful recruitment. METHODS AND ANALYSIS This review will scope the diverse literature surrounding sham surgery trials with the aim of informing a discrete choice experiment to empirically test patient and surgeon preferences for different sham surgery trial designs. The scoping review will be conducted in accordance with the methodological framework described in Arksey and O'Malley (2005) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. The review will be informed by a systematic search of Medline, Embase, PsycInfo, CINAHL and EconLit databases (from database inception to 21 June 2019), a Google Scholar search, and hand searching of reference lists of relevant studies or reviews. Studies or opinion pieces that involve patient, surgeon or trial characteristics, which influence the decision to participate in a trial, will be included. Study selection will be carried out independently by two authors with discrepancies resolved by consensus among three authors. Data will be charted using a standardised form, and results tabulated and narratively summarised with reference to the research questions of the review. ETHICS AND DISSEMINATION The findings from this review will inform the design of a discrete choice experiment around willingness to participate in surgical trials, the outcomes of which can inform decision and cost-effectiveness models of sham surgery RCTs. The qualitative information from this review will also inform patient-centred outcomes research. The review will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER CRD42019133296.
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Affiliation(s)
- Laura Wall
- Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, New South Wales, Australia
| | - Madeleine Hinwood
- Hunter Medical Research Institute, The University of Newcastle, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle Faculty of Health and Medicine, Newcastle, New South Wales, Australia
| | - Danielle Lang
- Hunter Medical Research Institute, The University of Newcastle, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle Faculty of Health and Medicine, Newcastle, New South Wales, Australia
| | - Angela Smith
- HNE Health Libraries, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Samantha Bunzli
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Philip Clarke
- School of Population and Global Health, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Health Economics Research Centre, Oxford University, Oxford, UK
| | - Peter F M Choong
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Michelle M Dowsey
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Francesco Paolucci
- Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, New South Wales, Australia
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17
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris IA, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Cook JA. Considerations and methods for placebo controls in surgical trials (ASPIRE guidelines). Lancet 2020; 395:828-838. [PMID: 32145797 DOI: 10.1016/s0140-6736(19)33137-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/13/2019] [Accepted: 12/06/2019] [Indexed: 01/09/2023]
Abstract
Placebo comparisons are increasingly being considered for randomised trials assessing the efficacy of surgical interventions. The aim of this Review is to provide a summary of knowledge on placebo controls in surgical trials. A placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. This Review outlines what a placebo control entails and present understanding of this tool in the context of surgery. We consider when placebo controls in surgery are acceptable (and when they are desirable) in terms of ethical arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be done and interpreted. Use of placebo controls is justified in randomised controlled trials of surgical interventions provided there is a strong scientific and ethical rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with high risk of bias, particularly because of the placebo effect. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. This Review forms an outline for best practice and provides guidance, in the form of the Applying Surgical Placebo in Randomised Evaluations (known as ASPIRE) checklist, for those considering the use of a placebo control in a surgical randomised controlled trial.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK.
| | - Marion K Campbell
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, UK
| | - Jane M Blazeby
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Charles Weijer
- Rotman Institute of Philosophy, Western Interdisciplinary Research Building, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Cabrini-Monash Department of Clinical Epidemiology, Cabrini Institute and Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, Heritage Building, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Department of Orthopaedics Lund, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK; University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Amar Rangan
- Department of Health Sciences, Seebohm Rowntree Building, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; Old Road Campus Research Building, University of Oxford, Oxford, UK
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Vase L, Wartolowska K. Pain, placebo, and test of treatment efficacy: a narrative review. Br J Anaesth 2019; 123:e254-e262. [PMID: 30915982 PMCID: PMC6676016 DOI: 10.1016/j.bja.2019.01.040] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 01/09/2023] Open
Abstract
Over the past decade, the mechanisms underlying placebo effects have begun to be identified. At the same time, the placebo response appears to have increased in pharmacological trials and marked placebo effects are found in neurostimulation and surgical trials, thereby posing the question whether non-pharmacological interventions should be placebo-controlled to a greater extent. In this narrative review we discuss how the knowledge of placebo mechanisms may help to improve placebo control in pharmacological and non-pharmacological trials. We review the psychological, neurobiological, and genetic mechanisms underlying placebo analgesia and outline the current problems and potential solutions to the challenges with placebo control in trials on pharmacological, neurostimulation, and surgical interventions. We particularly focus on how patients' perception of the therapeutic intervention, and their expectations towards treatment efficacy may help develop more precise placebo controls and blinding procedures and account for the contribution of placebo factors to the efficacy of active treatments. Finally, we discuss how systematic investigations into placebo mechanisms across various pain conditions and types of treatment are needed in order to 'personalise' the placebo control to the specific pathophysiology and interventions, which may ultimately lead to identification of more effective treatment for pain patients. In conclusion this review shows that it is important to understand how patients' perception and expectations influence the efficacy of active and placebo treatments in order to improve the test of new treatments. Importantly, this applies not only to assessment of drug efficacy but also to non-pharmacological trials on surgeries and stimulation procedures.
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Affiliation(s)
- Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark.
| | - Karolina Wartolowska
- Nuffield Department of Primary Care Health Services, University of Oxford, Oxford, UK.
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Roos EM, Hare KB, Nielsen SM, Christensen R, Lohmander LS. Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35-55 years with knee pain and an MRI-verified meniscal tear. BMJ Open 2018; 8:e019461. [PMID: 29420232 PMCID: PMC5829931 DOI: 10.1136/bmjopen-2017-019461] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Compare arthroscopic partial meniscectomy to a true sham intervention. METHODS Sham-controlled superiority trial performed in three county hospitals in Denmark comparing arthroscopic partial meniscectomy to skin incisions only in patients aged 35-55 years with persistent knee pain and an MRI-confirmed medial meniscus lesion. A computer-generated table of random numbers generated two comparison groups. Participants and outcome assessors were blinded to group allocation. Exclusions were locking knees, high-energy trauma or severe osteoarthritis. Outcomes were collected at baseline, 3 and 24 months. We hypothesised no difference between groups. The primary outcome was the between-group difference in change from baseline to 2 years in the mean score across all five normalised Knee injury and Osteoarthritis Outcome Score (KOOS) subscales (KOOS5). RESULTS Forty-four patients (of the estimated 72) underwent randomisation; 22 in each group. Sixteen participants (36%) were non-blinded and eight participants (36%) from the sham group crossed over to the surgery group prior to the 2-year follow-up. At 2 years, both groups reported clinically relevant improvements (surgery 21.8, skin incisions only 13.6), the mean difference between groups was 8.2 in favour of surgery, which is slightly less than the cut-off of 10 prespecified to represent a clinically relevant difference; judged by the 95% CI (-3.4 to 19.8), a possibility of clinically relevant difference could not be excluded. In total, nine participants experienced 11 adverse events; six in the surgery group and three in the skin-incisions-only group. CONCLUSION We found greater improvement from arthroscopic partial meniscectomy compared with skin incisions only at 2 years, with the statistical uncertainty of the between-group difference including what could be considered clinically relevant. Because of the study being underpowered, nearly half in the sham group being non-blinded and one-third crossing over to surgery, the results cannot be generalised to the greater patient population. TRIAL REGISTRATION NUMBER NCT01264991.
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Affiliation(s)
- Ewa M Roos
- Department of Sport and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Kristoffer Borbjerg Hare
- Department of Sport and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Orthopaedics, Slagelse Hospital, Slagelse, Denmark
| | - Sabrina Mai Nielsen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
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Savulescu J, Wartolowska K, Carr A. Randomised placebo-controlled trials of surgery: ethical analysis and guidelines. JOURNAL OF MEDICAL ETHICS 2016; 42:776-783. [PMID: 27777269 PMCID: PMC5256399 DOI: 10.1136/medethics-2015-103333] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 09/06/2016] [Accepted: 09/27/2016] [Indexed: 05/03/2023]
Abstract
Use of a placebo control in surgical trials is a divisive issue. We argue that, in principle, placebo controls for surgery are necessary in the same way as for medicine. However, there are important differences between these types of trial, which both increase justification and limit application of surgical studies. We propose that surgical randomised placebo-controlled trials are ethical if certain conditions are fulfilled: (1) the presence of equipoise, defined as a lack of unbiased evidence for efficacy of an intervention; (2) clinically important research question; (3) the risk to patients is minimised and reasonable; (4) there is uncertainty about treatment allocation rather than deception; (5) there is preliminary evidence for efficacy, which justifies a placebo-controlled design; and (6) ideally, the placebo procedure should have some direct benefit to the patient, for example, as a diagnostic tool. Placebo-controlled trials in surgery will most often be justified when surgery is performed to improve function or relieve symptoms and when objective outcomes are not available, while the risk of mortality or significant morbidity is low. In line with medical placebo-controlled trials, the surgical trial (1) should be sufficiently powered and (2) standardised so that its results are valid, (3) consent should be valid, (4) the standard treatment or rescue medication should be provided if possible, and (5) after the trial, the patients should be told which treatment they received and there should be provision for post-trial care if the study may result in long-term negative effects. We comment and contrast our guidelines with those of the American Medical Association.
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Affiliation(s)
- Julian Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, Oxford, UK
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Andy Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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21
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Wartolowska K, Collins GS, Hopewell S, Judge A, Dean BJF, Rombach I, Beard DJ, Carr AJ. Feasibility of surgical randomised controlled trials with a placebo arm: a systematic review. BMJ Open 2016; 6:e010194. [PMID: 27008687 PMCID: PMC4800115 DOI: 10.1136/bmjopen-2015-010194] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To find evidence, either corroborating or refuting, for many persisting beliefs regarding the feasibility of carrying out surgical randomised controlled trials with a placebo arm, with emphasis on the challenges related to recruitment, funding, anaesthesia or blinding. DESIGN Systematic review. DATA SOURCES AND STUDY SELECTION The analysis involved studies published between 1959 and 2014 that were identified during an earlier systematic review of benefits and harms of placebo-controlled surgical trials published in 2014. RESULTS 63 trials were included in the review. The main problem reported in many trials was a very slow recruitment rate, mainly due to the difficulty in finding eligible patients. Existing placebo trials were funded equally often from commercial and non-commercial sources. General anaesthesia or sedation was used in 41% of studies. Among the reviewed trials, 81% were double-blinded, and 19% were single-blinded. Across the reviewed trials, 96% (range 50-100%) of randomised patients completed the study. The withdrawal rate during the study was similar in the surgical and in the placebo groups. CONCLUSIONS This review demonstrated that placebo-controlled surgical trials are feasible, at least for procedures with a lower level of invasiveness, but also that recruitment is difficult. Many of the presumed challenges to undertaking such trials, for example, funding, anaesthesia or blinding of patients and assessors, were not reported as obstacles to completion in any of the reviewed trials.
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Affiliation(s)
- Karolina Wartolowska
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gary S Collins
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Oxford, UK
| | - Andrew Judge
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Benjamin J F Dean
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ines Rombach
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Beard
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Royal College of Surgeons of England Clinical Trials Unit, Botnar Institute of Musculoskeletal Sciences, Oxford, UK
| | - Andrew J Carr
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Royal College of Surgeons of England Clinical Trials Unit, Botnar Institute of Musculoskeletal Sciences, Oxford, UK
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George AJT, Collett C, Carr AJ, Holm S, Bale C, Burton S, Campbell M, Coles A, Gottlieb G, Muir K, Parroy S, Price J, Rice ASC, Sinden J, Stephenson C, Wartolowska K, Whittall H. When should placebo surgery as a control in clinical trials be carried out? ACTA ACUST UNITED AC 2016. [DOI: 10.1308/rcsbull.2016.75] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Placebo surgery – often maligned as ‘sham surgery’ – is a tough sell to patients and to many clinicians. But could surgical research benefit from increased use of placebo control groups?
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Niemansburg SL, van Delden JJ, Dhert WJ, Bredenoord AL. Reconsidering the ethics of sham interventions in an era of emerging technologies. Surgery 2015; 157:801-10. [DOI: 10.1016/j.surg.2014.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/13/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
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Reiman MP, Thorborg K. Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? Br J Sports Med 2015; 49:782-4. [PMID: 25677797 DOI: 10.1136/bjsports-2014-093821] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2015] [Indexed: 01/11/2023]
Abstract
Femoroacetabuler impingement (FAI) is becoming increasingly recognised as a potential pathological entity for individuals with hip pain. Surgery described to correct FAI has risen exponentially in the past 10 years with the use of hip arthroscopy. Unfortunately, the strength of evidence supporting both the examination and treatment of FAI does not appear to accommodate this exponential growth. In fact, the direction currently taken for FAI is similar to previously described paths of other orthopaedic and sports medicine pathologies (eg, shoulder impingement, knee meniscus tear) for which we have learned valuable lessons. The time has come for improved terminology, study design, and focus on delineation of successful treatment variables in the interest of those individuals with clinical indications of FAI so that we can appropriately address their needs.
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Affiliation(s)
- Michael P Reiman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Kristian Thorborg
- Sports Orthopedic Research Centre-Copenhagen (SORC-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark
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