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Deere R, Pallmann P, Shepherd V, Brookes-Howell L, Carson-Stevens A, Davies F, Dunphy E, Gupta P, Hickson M, Hill V, Ingarfield K, Ivins N, Jones F, Letchford R, Lowe R, Nash S, Otter P, Prout H, Randell E, Sewell B, Smith D, Trubey R, Wainwright T, Busse M, Button K. MulTI-domain self-management in older People wiTh OstEoarthritis and multi-morbidities: protocol for the TIPTOE randomised controlled trial. Trials 2024; 25:557. [PMID: 39180101 PMCID: PMC11344358 DOI: 10.1186/s13063-024-08380-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 08/06/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Four out of five people living with osteoarthritis (OA) also suffer with at least one other long-term health condition. The complex interaction between OA and multiple long-term conditions (MLTCs) can result in difficulties with self-care, restricted mobility, pain, anxiety, depression and reduced quality of life. The aim of the MulTI-domain Self-management in Older People wiTh OstEoarthritis and Multi-Morbidities (TIPTOE) trial is to evaluate the clinical and cost-effectiveness of the Living Well self-management support intervention, co-designed with people living with OA, integrated into usual care, in comparison to usual care alone. METHODS TIPTOE is a multi-centre, two-arm, individually randomised controlled trial where 824 individuals over 65 years old with knee and/or hip joint pain from their OA affected joint and at least one other long-term health condition will be randomised to receive either the Living Well Self-Management support intervention or usual care. Eligible participants can self-refer onto the trial via a website or be referred via NHS services across Wales and England. Those randomised to receive the Living Well support intervention will be offered up to six one-to-one coaching sessions with a TIPTOE-trained healthcare practitioner and a co-designed book. Participants will be encouraged to nominate a support person to assist them throughout the study. All participants will complete a series of self-reported outcome measures at baseline and 6- and 12-month follow-up. The primary outcome is symptoms and quality of life as assessed by the Musculoskeletal Health Questionnaire (MSK-HQ). Routine data will be used to evaluate health resource use. A mixed methods process evaluation will be conducted alongside the trial to inform future implementation should the TIPTOE intervention be found both clinically and cost-effective. An embedded 'Study Within A Project' (SWAP) will explore and address barriers to the inclusion of under-served patient groups (e.g. oldest old, low socioeconomic groups, ethnic groups). DISCUSSION TIPTOE will evaluate the clinical and cost-effectiveness of a co-designed, living well personalised self-management support intervention for older individuals with knee and/or hip OA and MLTCs. The trial has been designed to maximise inclusivity and access. TRIAL REGISTRATION ISRCTN 16024745 . Registered on October 16, 2023.
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Affiliation(s)
- Rachel Deere
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Victoria Shepherd
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Lucy Brookes-Howell
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Ffion Davies
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Emma Dunphy
- Healthcare NHS Foundation Trust is Homerton Hospital, Homerton Row, London, E9 6SR, UK
| | - Preeti Gupta
- Cardiff and Vale University Health Board, Heath Park, Cardiff, CF14 4XN, UK
| | - Mary Hickson
- School of Health Professions, University of Plymouth, Plymouth, UK
| | - Val Hill
- Public and Patient Involvement Member C/O Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Kate Ingarfield
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Nicola Ivins
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Fiona Jones
- Population Health Research Institute, St George's University, London, UK
- Bridges Self-Management, St George's University, London, UK
| | - Robert Letchford
- Cardiff and Vale University Health Board, Heath Park, Cardiff, CF14 4XN, UK
| | - Rachel Lowe
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Sarah Nash
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Paula Otter
- Bridges Self-Management, St George's University, London, UK
| | - Hayley Prout
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Elizabeth Randell
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Bernadette Sewell
- Faculty of Medicine, Health and Life Science, Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Debs Smith
- Public and Patient Involvement Member C/O Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Robert Trubey
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Tom Wainwright
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, UK
| | - Monica Busse
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Kate Button
- School of Healthcare Sciences, Cardiff University, Cardiff, UK.
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Dinart D, Rondeau V, Bellera C. Sample Size Estimation Using a Partially Clustered Frailty Model for Biomarker-Strategy Designs With Multiple Treatments. Pharm Stat 2024. [PMID: 39014905 DOI: 10.1002/pst.2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/08/2024] [Accepted: 05/14/2024] [Indexed: 07/18/2024]
Abstract
Biomarker-guided therapy is a growing area of research in medicine. To optimize the use of biomarkers, several study designs including the biomarker-strategy design (BSD) have been proposed. Unlike traditional designs, the emphasis here is on comparing treatment strategies and not on treatment molecules as such. Patients are assigned to either a biomarker-based strategy (BBS) arm, in which biomarker-positive patients receive an experimental treatment that targets the identified biomarker, or a non-biomarker-based strategy (NBBS) arm, in which patients receive treatment regardless of their biomarker status. We proposed a simulation method based on a partially clustered frailty model (PCFM) as well as an extension of Freidlin formula to estimate the sample size required for BSD with multiple targeted treatments. The sample size was mainly influenced by the heterogeneity of treatment effect, the proportion of biomarker-negative patients, and the randomization ratio. The PCFM is well suited for the data structure and offers an alternative to traditional methodologies.
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Affiliation(s)
- Derek Dinart
- Bordeaux Population Health Research Center, Epicene Team, U1219, University of Bordeaux, Inserm, Bordeaux, France
- Inserm CIC1401, Clinical and Epidemiological Research Unit, Institut Bergonie, Comprehensive Cancer Center, Bordeaux, France
| | - Virginie Rondeau
- Bordeaux Population Health Research Center, Epicene Team, U1219, University of Bordeaux, Inserm, Bordeaux, France
- Biostatistic Team, University of Bordeaux, Bordeaux, France
| | - Carine Bellera
- Bordeaux Population Health Research Center, Epicene Team, U1219, University of Bordeaux, Inserm, Bordeaux, France
- Inserm CIC1401, Clinical and Epidemiological Research Unit, Institut Bergonie, Comprehensive Cancer Center, Bordeaux, France
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3
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Burton C, Mooney C, Sutton L, White D, Dawson J, Neilson AR, Rowlands G, Thomas S, Horspool M, Fryer K, Greco M, Sanders T, Thomas RE, Cooper C, Turton E, Waheed W, Woodward J, Mallender E, Deary V. Effectiveness of a symptom-clinic intervention delivered by general practitioners with an extended role for people with multiple and persistent physical symptoms in England: the Multiple Symptoms Study 3 pragmatic, multicentre, parallel-group, individually randomised controlled trial. Lancet 2024; 403:2619-2629. [PMID: 38879261 DOI: 10.1016/s0140-6736(24)00700-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND People with multiple and persistent physical symptoms have impaired quality of life and poor experiences of health care. We aimed to evaluate the effectiveness of a community-based symptom-clinic intervention in people with multiple and persistent physical symptoms, hypothesising that this symptoms clinic plus usual care would be superior to usual care only. METHODS The Multiple Symptoms Study 3 was a pragmatic, multicentre, parallel-group, individually randomised controlled trial conducted in 108 general practices in the UK National Health Service in four regions of England between Dec 6, 2018, and June 30, 2023. Participants were individually randomised (1:1) to the symptom-clinic intervention plus usual care or to usual care only via a computer-generated, pseudo-random list stratified by trial centre. Allocation was done by the trial statistician and concealed with a centralised, web-based randomisation system; masking participants was not possible due to the nature of the intervention. The symptom-clinic intervention was a sequence of up to four medical consultations that aimed to elicit a detailed clinical history, fully hear and validate the participant, offer rational explanations for symptoms, and assist the participant to develop ways of managing their symptoms; it was delivered by general practitioners with an extended role. The primary outcome was Patient Health Questionnaire-15 (PHQ-15) score 52 weeks after randomisation, analysed by intention to treat. The trial is registered on the ISRCTN registry (ISRCTN57050216). FINDINGS 354 participants were randomly assigned; 178 (50%) were assigned to receive the community-based symptoms clinic plus usual care and 176 (50%) were assigned to receive usual care only. At the primary-outcome point of 52 weeks, PHQ-15 scores were 14·1 (SD 3·7) in the group receiving usual care and 12·2 (4·5) in the group receiving the intervention. The adjusted between-group difference of -1·82 (95% CI -2·67 to -0·97) was statistically significantly in favour of the intervention group (p<0·0001). There were 39 adverse events in the group receiving usual care and 36 adverse events in the group receiving the intervention. There were no statistically significant between-group differences in the proportion of participants who had non-serious adverse events (-0·03, 95% CI -0·11 to 0·05) or serious adverse events (0·02, -0·02 to 0·07). No serious adverse event was deemed to be related to the trial intervention. INTERPRETATION Our symptom-clinic intervention, which focused on explaining persistent symptoms to participants in order to support self-management, led to sustained improvement in multiple and persistent physical symptoms. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
| | - Cara Mooney
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Laura Sutton
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - David White
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Jeremy Dawson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK; Sheffield University Management School, University of Sheffield, Sheffield, UK
| | - Aileen R Neilson
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Gillian Rowlands
- Public Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Steve Thomas
- South Yorkshire Integrated Care Board, Sheffield, UK
| | | | - Kate Fryer
- Division of Population Health, University of Sheffield, Sheffield, UK
| | - Monica Greco
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Tom Sanders
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Ruth E Thomas
- Centre for Healthcare Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Emily Turton
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Waquas Waheed
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jonathan Woodward
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Vincent Deary
- Department of Psychology, Northumbria University, Newcastle upon Tyne, UK
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4
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Ali MK, Singh K, Kondal D, Devarajan R, Patel SA, Menon VU, Varthakavi PK, Vishwanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Prabhakaran D, Narayan KMV, Tandon N. Effect of a multicomponent quality improvement strategy on sustained achievement of diabetes care goals and macrovascular and microvascular complications in South Asia at 6.5 years follow-up: Post hoc analyses of the CARRS randomized clinical trial. PLoS Med 2024; 21:e1004335. [PMID: 38829880 PMCID: PMC11198027 DOI: 10.1371/journal.pmed.1004335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/25/2024] [Accepted: 04/22/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Diabetes control is poor globally and leads to burdensome microvascular and macrovascular complications. We aimed to assess post hoc between-group differences in sustained risk factor control and macrovascular and microvascular endpoints at 6.5 years in the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomized trial. METHODS AND FINDINGS This parallel group individual randomized clinical trial was performed at 10 outpatient diabetes clinics in India and Pakistan from January 2011 through September 2019. A total of 1,146 patients with poorly controlled type 2 diabetes (HbA1c ≥8% and systolic BP ≥140 mm Hg and/or LDL-cholesterol ≥130 mg/dL) were randomized to a multicomponent quality improvement (QI) strategy (trained nonphysician care coordinator to facilitate care for patients and clinical decision support system for physicians) or usual care. At 2.5 years, compared to usual care, those receiving the QI strategy were significantly more likely to achieve multiple risk factor control. Six clinics continued, while 4 clinics discontinued implementing the QI strategy for an additional 4-year follow-up (overall median 6.5 years follow-up). In this post hoc analysis, using intention-to-treat, we examined between-group differences in multiple risk factor control (HbA1c <7% plus BP <130/80 mm Hg and/or LDL-cholesterol <100 mg/dL) and first macrovascular endpoints (nonfatal myocardial infarction, nonfatal stroke, death, revascularization [angioplasty or coronary artery bypass graft]), which were co-primary outcomes. We also examined secondary outcomes, namely, single risk factor control, first microvascular endpoints (retinopathy, nephropathy, neuropathy), and composite first macrovascular plus microvascular events (which also included amputation and all-cause mortality) by treatment group and whether QI strategy implementation was continued over 6.5 years. At 6.5 years, assessment data were available for 854 participants (74.5%; n = 417 [intervention]; n = 437 [usual care]). In terms of sociodemographic and clinical characteristics, participants in the intervention and usual care groups were similar and participants at sites that continued were no different to participants at sites that discontinued intervention implementation. Patients in the intervention arm were more likely to exhibit sustained multiple risk factor control than usual care (relative risk: 1.77; 95% confidence interval [CI], 1.45, 2.16), p < 0.001. Cumulatively, there were 233 (40.5%) first microvascular and macrovascular events in intervention and 274 (48.0%) in usual care patients (absolute risk reduction: 7.5% [95% CI: -13.2, -1.7], p = 0.01; hazard ratio [HR] = 0.72 [95% CI: 0.61, 0.86]), p < 0.001. Patients in the intervention arm experienced lower incidence of first microvascular endpoints (HR = 0.68 [95% CI: 0.56, 0.83), p < 0.001, but there was no evidence of between-group differences in first macrovascular events. Beneficial effects on microvascular and composite vascular outcomes were observed in sites that continued, but not sites that discontinued the intervention. CONCLUSIONS In urban South Asian clinics, a multicomponent QI strategy led to sustained multiple risk factor control and between-group differences in microvascular, but not macrovascular, endpoints. Between-group reductions in vascular outcomes at 6.5 years were observed only at sites that continued the QI intervention, suggesting that practice change needs to be maintained for better population health of people with diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT01212328.
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Affiliation(s)
- Mohammed K. Ali
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, United States of America
| | - Kavita Singh
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Public Health Foundation of India, Gurgaon, India
| | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India
| | | | - Shivani A. Patel
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, United States of America
- Emory University, Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - V. Usha Menon
- Amrita Institute of Medical Sciences, Department of Endocrinology & Diabetes, AIMS Ponekkara, Kochi, India
| | | | | | - Mala Dharmalingam
- Bangalore Endocrinology & Diabetes Research Centre, Bangalore, India
| | - Ganapati Bantwal
- St. John’s Medical College & Hospital, Department of Endocrinology, Bangalore, India
| | | | - Muhammad Qamar Masood
- Aga Khan University, Department of Medicine, Section of Endocrinology and Diabetes, Karachi, Pakistan
| | - Rajesh Khadgawat
- All India Institute of Medical Sciences, Department of Endocrinology & Metabolism, Biotechnology Block, New Delhi, India
| | - Ankush Desai
- Goa Medical College, Department of Endocrinology, Bambolim, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - K. M. Venkat Narayan
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, United States of America
| | - Nikhil Tandon
- All India Institute of Medical Sciences, Department of Endocrinology & Metabolism, Biotechnology Block, New Delhi, India
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McNaught E, Reale S, Bourke L, Brown JE, Collinson M, Day F, Hewison J, Farrin AJ, Ibeggazene S, Innes AQ, Mason E, Meads D, Scope A, Taylor C, Taylor SJ, Turner RR, Rosario DJ. Supported exercise TrAining for Men wIth prostate caNcer on Androgen deprivation therapy (STAMINA): study protocol for a randomised controlled trial of the clinical and cost-effectiveness of the STAMINA lifestyle intervention compared with optimised usual care, including internal pilot and parallel process evaluation. Trials 2024; 25:257. [PMID: 38610058 PMCID: PMC11010375 DOI: 10.1186/s13063-024-07989-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/05/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND UK national clinical guidance recommends that men with prostate cancer on androgen deprivation therapy are offered twice weekly supervised aerobic and resistance exercise to address iatrogenic harm caused by treatment. Very few NHS trusts have established adequate provision of such services. Furthermore, interventions fail to demonstrate sustained behaviour change. The STAMINA lifestyle intervention offers a system-level change to clinical care delivery addressing barriers to long-term behaviour change and implementation of new prostate cancer care pathways. This trial aims to establish whether STAMINA is clinically and cost-effective in improving cancer-specific quality of life and/or reducing fatigue compared to optimised usual care. The process evaluation aims to inform the interpretation of results and, if the intervention is shown to benefit patients, to inform the implementation of the intervention into the NHS. METHODS Men with prostate cancer on androgen deprivation therapy (n = 697) will be identified from a minimum of 12 UK NHS trusts to participate in a multi-centre, two-arm, individually randomised controlled trial. Consenting men will have a 'safety to exercise' check and be randomly allocated (5:4) to the STAMINA lifestyle intervention (n = 384) or optimised usual care (n = 313). Outcomes will be collected at baseline, 3-, 6- and 12-month post-randomisation. The two primary outcomes are cancer-specific quality of life and fatigue. The parallel process evaluation will follow a mixed-methods approach to explore recruitment and aspects of the intervention including, reach, fidelity, acceptability, and implementation. An economic evaluation will estimate the cost-effectiveness of the STAMINA lifestyle intervention versus optimised usual care and a discrete choice experiment will explore patient preferences. DISCUSSION The STAMINA lifestyle intervention has the potential to improve quality of life and reduce fatigue in men on androgen deprivation therapy for prostate cancer. Embedding supervised exercise into prostate cancer care may also support long-term positive behaviour change and reduce adverse events caused by treatment. Findings will inform future clinical care and could provide a blueprint for the integration of supervised exercise and behavioural support into other cancer and/or clinical services. TRIAL REGISTRATION ISRCTN 46385239, registered on 30/07/2020. Cancer Research UK 17002, retrospectively registered on 24/08/2022.
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Affiliation(s)
- Emma McNaught
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Sophie Reale
- Department of Allied Health Professions, Sheffield Hallam University, Sheffield, S10 2BP, UK
| | - Liam Bourke
- Department of Allied Health Professions, Sheffield Hallam University, Sheffield, S10 2BP, UK
| | - Janet E Brown
- Division of Clinical Medicine, University of Sheffield, Sheffield, S10 2RX, UK
| | - Michelle Collinson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Florence Day
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Jenny Hewison
- Division of Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK
| | - Amanda J Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Saïd Ibeggazene
- Department of Allied Health Professions, Sheffield Hallam University, Sheffield, S10 2BP, UK
| | - Aidan Q Innes
- Nuffield Health, 2 Ashley Avenue, Epsom, Surrey, KT18 5AL, UK
| | - Ellen Mason
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK
| | - Alison Scope
- Department of Allied Health Professions, Sheffield Hallam University, Sheffield, S10 2BP, UK
| | - Chris Taylor
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Steph Jc Taylor
- Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
| | - Rebecca R Turner
- Division of Psychology and Mental Health in the School of Health Sciences, The University of Manchester, Manchester, M13 9PL, UK
| | - Derek J Rosario
- Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
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Viding E, Lloyd A, Law R, Martin P, Lucas L, Wu TCH, Steinbeis N, Midgley N, Veenstra R, Smith J, Ly L, Bird G, Murphy J, Plans D, Munafo M, Penton-Voak I, Deighton J, Richards K, Richards M, Fearon P. Trial protocol for the Building Resilience through Socio-Emotional Training (ReSET) programme: a cluster randomised controlled trial of a new transdiagnostic preventative intervention for adolescents. Trials 2024; 25:143. [PMID: 38395922 PMCID: PMC10885387 DOI: 10.1186/s13063-024-07931-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Adolescence is a period of heightened vulnerability to developing mental health problems, and rates of mental health disorder in this age group have increased in the last decade. Preventing mental health problems developing before they become entrenched, particularly in adolescents who are at high risk, is an important research and clinical target. Here, we report the protocol for the trial of the 'Building Resilience through Socioemotional Training' (ReSET) intervention. ReSET is a new, preventative intervention that incorporates individual-based emotional training techniques and group-based social and communication skills training. We take a transdiagnostic approach, focusing on emotion processing and social mechanisms implicated in the onset and maintenance of various forms of psychopathology. METHODS A cluster randomised allocation design is adopted with randomisation at the school year level. Five-hundred and forty adolescents (aged 12-14) will be randomised to either receive the intervention or not (passive control). The intervention is comprised of weekly sessions over an 8-week period, supplemented by two individual sessions. The primary outcomes, psychopathology symptoms and mental wellbeing, will be assessed pre- and post-intervention, and at a 1-year follow-up. Secondary outcomes are task-based assessments of emotion processing, social network data based on peer nominations, and subjective ratings of social relationships. These measures will be taken at baseline, post-intervention and 1-year follow-up. A subgroup of participants and stakeholders will be invited to take part in focus groups to assess the acceptability of the intervention. DISCUSSION This project adopts a theory-based approach to the development of a new intervention designed to target the close connections between young people's emotions and their interpersonal relationships. By embedding the intervention within a school setting and using a cluster-randomised design, we aim to develop and test a feasible, scalable intervention to prevent the onset of psychopathology in adolescence. TRIAL REGISTRATION ISRCTN88585916. Trial registration date: 20/04/2023.
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Affiliation(s)
- Essi Viding
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK.
| | - Alex Lloyd
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK
| | - Roslyn Law
- Anna Freud National Centre for Children and Families, London, UK
| | - Peter Martin
- Applied Health Research Institute of Epidemiology & Health, University College London, London, UK
| | - Laura Lucas
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK
| | - Tom Chin-Han Wu
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK
| | - Nikolaus Steinbeis
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK
| | - Nick Midgley
- Anna Freud National Centre for Children and Families, London, UK
| | - René Veenstra
- Department of Sociology, University of Groningen, Groningen, Germany
| | - Jaime Smith
- Anna Freud National Centre for Children and Families, London, UK
| | - Lili Ly
- Anna Freud National Centre for Children and Families, London, UK
| | - Geoffrey Bird
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Jennifer Murphy
- Department of Psychology, Royal Holloway, University of London, London, UK
| | - David Plans
- Department of Psychology, Royal Holloway, University of London, London, UK
| | - Marcus Munafo
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol Medical School, University of Bristol, Bristol, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Ian Penton-Voak
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Jessica Deighton
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK
- Anna Freud National Centre for Children and Families, London, UK
| | | | | | - Pasco Fearon
- Clinical, Educational and Health Psychology, Psychology and Language Sciences, University College London, 26 Bedford Way, London, WC1H 0AP, UK.
- Centre for Family Research, Department of Psychology, University of Cambridge, Downing Pl, Cambridge, CB2 3EB, UK.
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7
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Rosan C, Dijk KAV, Darwin Z, Babalis D, Cornelius V, Phillips R, Richards L, Wright H, Pilling S, Fearon P, Pizzo E, Fonagy P. The COSI trial: a study protocol for a multi-centre, randomised controlled trial to explore the clinical and cost-effectiveness of the Circle of Security-Parenting Intervention in community perinatal mental health services in England. Trials 2023; 24:188. [PMID: 36915170 PMCID: PMC10012495 DOI: 10.1186/s13063-023-07194-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/20/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Perinatal mental health difficulties affect up to 27% of birthing parents during pregnancy and the first postnatal year, and if untreated are associated with difficulties in bonding and long-term adverse outcomes to children. There are large evidence gaps related to psychological treatment, particularly in group therapy approaches and parent-infant interventions. One intervention showing preliminary efficacious findings and user acceptability is Circle of Security-Parenting (COS-P), which is a brief, weekly, group programme. However, these studies were underpowered and predominantly non-randomised, and there has never been a research trial in England or with birthing parents experiencing severe and complex perinatal mental health difficulties. The aim of the research is to conduct a randomised control trial to test whether COS-P will reduce perinatal mental health symptoms in birthing parents accessing NHS perinatal mental health services, compared to treatment as usual (TAU). Secondary objectives include exploring whether the intervention improves parenting sensitivity, emotion regulation skills, attachment security and infant development. Additionally, the project aims to examine whether the intervention is acceptable to parents and NHS staff, and whether it is cost-effective. METHODS COSI is an individually randomised, single-blind parallel arm controlled trial with an embedded internal pilot aiming to recruit 369 participants in a 2:1 ratio (intervention: TAU). Participants will be recruited from ten NHS community perinatal mental health services in England and screened based on clinical levels of both mental health symptoms (average CORE-OM score ≥ 1.1) and postnatal bonding difficulties (total PBQ score ≥ 12). This trial has 90% power to detect a MCID of 5 points on the CORE-OM. Primary and secondary outcomes will be measured at baseline, 3, 7 and 12 months after baseline. Service use and quality of life measures will also be collected alongside a process evaluation of parents' and interveners' views and experiences. DISCUSSION This will be the first large pragmatic trial to test whether COS-P is effective for birthing parents with severe and complex perinatal mental health difficulties in improving their mental health symptoms. If shown to be effective, the intervention could be delivered widely across the NHS and other similar services globally. TRIAL REGISTRATION ISRCTN, ISRCTN18308962. Registered 18 February 2022.
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Affiliation(s)
- Camilla Rosan
- Department of Clinical, Educational and Health Psychology, University College London, London, UK. .,Anna Freud National Centre for Children and Families, 4-8 Rodney St, London, N1 9JH, UK.
| | | | - Zoe Darwin
- University of Huddersfield, Huddersfield, UK
| | - Daphne Babalis
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Rachel Phillips
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Lani Richards
- Anna Freud National Centre for Children and Families, 4-8 Rodney St, London, N1 9JH, UK
| | - Hannah Wright
- Department of Clinical, Educational and Health Psychology, University College London, London, UK.,Anna Freud National Centre for Children and Families, 4-8 Rodney St, London, N1 9JH, UK
| | - Steve Pilling
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Pasco Fearon
- Department of Clinical, Educational and Health Psychology, University College London, London, UK.,Department of Psychology, University of Cambridge, Cambridge, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - Peter Fonagy
- Department of Clinical, Educational and Health Psychology, University College London, London, UK.,Anna Freud National Centre for Children and Families, 4-8 Rodney St, London, N1 9JH, UK
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8
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Potter C, Leggat F, Lowe R, Pallmann P, Riaz M, Barlow C, Edwards A, Siriwardena AN, Sevdalis N, Sewell B, McRae J, Fish J, de Sousa de Abreu MI, Jones F, Busse M. Effectiveness and cost-effectiveness of a personalised self-management intervention for living with long COVID: protocol for the LISTEN randomised controlled trial. Trials 2023; 24:75. [PMID: 36726167 PMCID: PMC9890432 DOI: 10.1186/s13063-023-07090-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Individuals living with long COVID experience multiple, interacting and fluctuating symptoms which can have a dramatic impact on daily living. The aim of the Long Covid Personalised Self-managemenT support EvaluatioN (LISTEN) trial is to evaluate effects of the LISTEN co-designed self-management support intervention for non-hospitalised people living with long COVID on participation in routine activities, social participation, emotional well-being, quality of life, fatigue, and self-efficacy. Cost-effectiveness will also be evaluated, and a detailed process evaluation carried out to understand how LISTEN is implemented. METHODS The study is a pragmatic randomised effectiveness and cost-effectiveness trial in which a total of 558 non-hospitalised people with long COVID will be randomised to either the LISTEN intervention or usual care. Recruitment strategies have been developed with input from the LISTEN Patient and Public Involvement and Engagement (PPIE) advisory group and a social enterprise, Diversity and Ability, to ensure inclusivity. Eligible participants can self-refer into the trial via a website or be referred by long COVID services. All participants complete a range of self-reported outcome measures, online, at baseline, 6 weeks, and 3 months post randomisation (the trial primary end point). Those randomised to the LISTEN intervention are offered up to six one-to-one sessions with LISTEN-trained intervention practitioners and given a co-designed digital resource and paper-based book. A detailed process evaluation will be conducted alongside the trial to inform implementation approaches should the LISTEN intervention be found effective and cost-effective. DISCUSSION The LISTEN trial is evaluating a co-designed, personalised self-management support intervention (the LISTEN intervention) for non-hospitalised people living with long COVID. The design has incorporated extensive strategies to minimise participant burden and maximise access. Whilst the duration of follow-up is limited, all participants are approached to consent for long-term follow-up (subject to additional funding being secured). TRIAL REGISTRATION LISTEN ISRCTN36407216. Registered on 27/01/2022.
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Affiliation(s)
- Claire Potter
- grid.5600.30000 0001 0807 5670Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales UK
| | - Fiona Leggat
- grid.264200.20000 0000 8546 682XPopulation Health Research Institute, St George’s University of London, London, England, UK ,grid.15538.3a0000 0001 0536 3773Faculty of Health, Social Care and Education, Kingston University, London, London, England, UK
| | - Rachel Lowe
- grid.5600.30000 0001 0807 5670Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales UK
| | - Philip Pallmann
- grid.5600.30000 0001 0807 5670Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales UK
| | - Muhammad Riaz
- grid.5600.30000 0001 0807 5670Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales UK
| | - Christy Barlow
- grid.5600.30000 0001 0807 5670Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales UK
| | - Adrian Edwards
- grid.5600.30000 0001 0807 5670PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales UK ,Wales COVID-19 Evidence Centre, Cardiff, Wales UK
| | | | - Nick Sevdalis
- grid.13097.3c0000 0001 2322 6764Centre for Implementation Science, King’s College London, London, UK
| | - Bernadette Sewell
- grid.4827.90000 0001 0658 8800Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Jackie McRae
- grid.264200.20000 0000 8546 682XPopulation Health Research Institute, St George’s University of London, London, England, UK ,grid.15538.3a0000 0001 0536 3773Faculty of Health, Social Care and Education, Kingston University, London, London, England, UK
| | - Jessica Fish
- grid.8756.c0000 0001 2193 314XDepartment of Clinical Neuropsychology & Clinical Health Psychology, St George’s University Hospitals NHS Foundation Trust and Mental Health & Wellbeing, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Maria Ines de Sousa de Abreu
- grid.439656.b0000 0004 0466 4605East Sussex Healthcare NHS Trust Crisis Response Service, St. Annes House, St Leonards-on-Sea, East Sussex UK
| | - Fiona Jones
- grid.264200.20000 0000 8546 682XPopulation Health Research Institute, St George’s University of London, London, England, UK ,grid.15538.3a0000 0001 0536 3773Faculty of Health, Social Care and Education, Kingston University, London, London, England, UK ,Bridges Self-Management, London, England, UK
| | - Monica Busse
- grid.5600.30000 0001 0807 5670Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales UK
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9
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Stathi A, Withall J, Greaves CJ, Thompson JL, Taylor G, Medina-Lara A, Green C, Snowsill T, Johansen-Berg H, Bilzon J, Gray S, Cross R, Western MJ, Koning JLD, Ladlow P, Bollen JC, Moorlock SJ, Guralnik JM, Rejeski WJ, Hillsdon M, Fox KR. A group-based exercise and behavioural maintenance intervention for adults over 65 years with mobility limitations: the REACT RCT. PUBLIC HEALTH RESEARCH 2022. [DOI: 10.3310/mqbw6832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background
Mobility limitation in older age reduces quality of life, generates substantial health- and social-care costs, and increases mortality.
Objective
The REtirement in ACTion (REACT) trial aimed to establish whether or not a community-based active ageing intervention could prevent decline in physical functioning in older adults already at increased risk of mobility limitation.
Design
A multicentre, pragmatic, two-arm, parallel-group randomised controlled trial with parallel process and health economic evaluations.
Setting
Urban and semi-rural locations across three sites in England.
Participants
Physically frail or pre-frail older adults (aged ≥ 65 years; Short Physical Performance Battery score of 4–9). Recruitment was primarily via 35 primary care practices.
Interventions
Participants were randomly assigned to receive brief advice (three healthy ageing education sessions) or a 12-month, group-based, multimodal exercise and behavioural maintenance programme delivered in fitness and community centres. Randomisation was stratified by site and used a minimisation algorithm to balance age, sex and Short Physical Performance Battery score. Data collection and analyses were blinded.
Main outcome measures
The primary outcome was change in lower limb physical function (Short Physical Performance Battery score) at 24 months, analysed using an intention-to-treat analysis. The economic evaluation adopted the NHS and Personal Social Services perspective.
Results
Between June 2016 and October 2017, 777 participants (mean age 77.6 years, standard deviation 6.8 years; 66% female; mean Short Physical Performance Battery score 7.37, standard deviation 1.56) were randomised to the intervention arm (n = 410) or the control arm (n = 367). Data collection was completed in October 2019. Primary outcome data at 24 months were provided by 628 (80.8%) participants. At the 24-month follow-up, the Short Physical Performance Battery score was significantly greater in the intervention arm (mean 8.08, standard deviation 2.87) than in the control arm (mean 7.59, standard deviation 2.61), with an adjusted mean difference of 0.49 (95% confidence interval 0.06 to 0.92). The difference in lower limb function between intervention and control participants was clinically meaningful at both 12 and 24 months. Self-reported physical activity significantly increased in the intervention arm compared with the control arm, but this change was not observed in device-based physical activity data collected during the trial. One adverse event was related to the intervention. Attrition rates were low (19% at 24 months) and adherence was high. Engagement with the REACT intervention was associated with positive changes in exercise competence, relatedness and enjoyment and perceived physical, social and mental well-being benefits. The intervention plus usual care was cost-effective compared with care alone over the 2 years of REACT; the price year was 2019. In the base-case scenario, the intervention saved £103 per participant, with a quality-adjusted life-year gain of 0.04 (95% confidence interval 0.006 to 0.074) within the 2-year trial window. Lifetime horizon modelling estimated that further cost savings and quality-adjusted life-year gains were accrued up to 15 years post randomisation.
Conclusion
A relatively low-resource, 1-year multimodal exercise and behavioural maintenance intervention can help older adults to retain physical functioning over a 24-month period. The results indicate that the well-established trajectory of declining physical functioning in older age is modifiable.
Limitations
Participants were not blinded to study arm allocation. However, the primary outcome was independently assessed by blinded data collectors. The secondary outcome analyses were exploratory, with no adjustment for multiple testing, and should be interpreted accordingly.
Future work
Following refinements guided by the process evaluation findings, the REACT intervention is suitable for large-scale implementation. Further research will optimise implementation of REACT at scale.
Trial registration
This trial is registered as ISRCTN45627165.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Afroditi Stathi
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | | | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Janice L Thompson
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Gordon Taylor
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | | | - Colin Green
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Tristan Snowsill
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Heidi Johansen-Berg
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Wellcome Centre for Integrative Neuroimaging, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - James Bilzon
- Department for Health, University of Bath, Bath, UK
| | - Selena Gray
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | - Rosina Cross
- Department for Health, University of Bath, Bath, UK
| | | | | | - Peter Ladlow
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
| | - Jessica C Bollen
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Sarah J Moorlock
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - W Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Worrell Professional Centre, Winston-Salem, NC, USA
| | - Melvyn Hillsdon
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Kenneth R Fox
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
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10
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Mead G, Gillespie D, Barber M, House A, Lewis S, Ensor H, Wu S, Chalder T. Post stroke intervention trial in fatigue (POSITIF): Randomised multicentre feasibility trial. Clin Rehabil 2022; 36:1578-1589. [PMID: 35866206 PMCID: PMC9574032 DOI: 10.1177/02692155221113908] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 06/16/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To test the feasibility of a telephone delivered intervention, informed by cognitive behavioural principles, for post-stroke fatigue, and estimated its effect on fatigue and other outcomes. DESIGN Randomised controlled parallel group trial. SETTING Three Scottish stroke services. SUBJECTS Stroke survivors with fatigue three months to two years post-stroke onset. INTERVENTIONS Seven telephone calls (fortnightly then a 'booster session' at 16 weeks) of a manualised intervention, plus information about fatigue, versus information only. MAIN MEASURES Feasibility of trial methods, and collected outcome measures (fatigue, mood, anxiety, social participation, quality of life, return to work) just before randomisation, at the end of treatment (four months after randomisation) and at six months after randomisation. RESULTS Between October 2018 and January 2020, we invited 886 stroke survivors to participate in postal screening: 188/886 (21%) returned questionnaires and consented, of whom 76/188 (40%) were eligible and returned baseline forms; 64/76 (84%) returned six month follow-up questionnaires. Of the 39 allocated the intervention, 23 (59%) attended at least four sessions. At six months, there were no significant differences between the groups (adjusted mean differences in Fatigue Assessment Scale -0.619 (95% CI -4.9631, 3.694; p = 0.768), the Generalised Anxiety Disorder 7 -0.178 (95% CI -3.823, 3.467, p = 0.92), and the Patient Health Questionnaire -0.247 (95% CI -2.935, 2.442, p = 0.851). There were no between-group differences in quality of life, social participation or return to work. CONCLUSION Patients can be recruited to a trial of this design. These data will inform the design of further trials in post-stroke fatigue.
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Affiliation(s)
- Gillian Mead
- Usher institute, University of Edinburgh, Edinburgh, UK
| | - David Gillespie
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Mark Barber
- NHS Lanarkshire, University Hospital Monklands, Coatbridge, UK
| | - Allan House
- Leeds Institute of Health Sciences, Leeds, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Hannah Ensor
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Trudie Chalder
- Department of Psychological Medicine, Kings College London, London, UK
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11
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Dow DE, O'Donnell KE, Mkumba L, Gallis JA, Turner EL, Boshe J, Shayo AM, Cunningham CK, Mmbaga BT. Sauti ya Vijana (SYV; The Voice of Youth): Longitudinal Outcomes of an Individually Randomized Group Treatment Pilot Trial for Young People Living with HIV in Tanzania. AIDS Behav 2022; 26:2015-2025. [PMID: 35067831 PMCID: PMC8784208 DOI: 10.1007/s10461-021-03550-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 01/09/2023]
Abstract
Sauti ya Vijana is a mental health and life skills intervention delivered by young adult group leaders for the improvement of HIV outcomes in young people living with HIV in Tanzania. This pilot randomized controlled trial estimated exploratory intervention effectiveness compared to standard of care. YPLWH (N = 105) were randomized to receive intervention or SOC. The mean age of participants was 18.1 years and 53% were female. Mean scores on mental health measures (Patient Health Questionnaire [PHQ-9], Strengths and Difficulties Questionnaire [SDQ], UCLA Trauma) were asymptomatic to mild in both study arms through 30-month follow-up with a non-significant fluctuation of 1-2 points. The mean self-reported adherence was higher in the intervention arm across all time points (but the confidence interval contained the null at all time points except 6 months). Risk ratio of virologic suppression (HIV RNA < 400 copies/mL) in the intervention arm compared to SOC was 1.15 [95% CI = 0.95, 1.39]) at 6-months, 1.17 [95% CI: 0.92, 1.48] at 12-months, and 0.99 [95% CI 0.76, 1.31] at 18-months. Though these findings were not powered for statistical significance, the trends in HIV outcomes suggest that SYV holds promise for improving antiretroviral therapy (ART) adherence and virologic suppression in YPLWH.
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Affiliation(s)
- Dorothy E Dow
- Department of Pediatrics, Infectious Diseases, Duke University Medical Center, Durham, NC, USA.
- Duke Global Health Institute, Box 3499, Durham, NC, 27710, USA.
| | - Karen E O'Donnell
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA
- Center for Child and Family Health, Durham, NC, USA
| | - Laura Mkumba
- Family Health International 360, Durham, NC, USA
| | - John A Gallis
- Duke Global Health Institute, Box 3499, Durham, NC, 27710, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Elizabeth L Turner
- Duke Global Health Institute, Box 3499, Durham, NC, 27710, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Judith Boshe
- Department of Psychiatry, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Aisa M Shayo
- Department of Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Coleen K Cunningham
- Department of Pediatrics, Infectious Diseases, Duke University Medical Center, Durham, NC, USA
- Duke Global Health Institute, Box 3499, Durham, NC, 27710, USA
| | - Blandina T Mmbaga
- Duke Global Health Institute, Box 3499, Durham, NC, 27710, USA
- Department of Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
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12
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Mountain G, Wright J, Cooper CL, Lee E, Sprange K, Beresford-Dent J, Young T, Walters S, Berry K, Dening T, Loban A, Turton E, Thomas BD, Young EL, Thompson BJ, Crawford B, Craig C, Bowie P, Moniz-Cook E, Foster A. An intervention to promote self-management, independence and self-efficacy in people with early-stage dementia: the Journeying through Dementia RCT. Health Technol Assess 2022; 26:1-152. [PMID: 35536231 DOI: 10.3310/khha0861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are few effective interventions for dementia. AIM To determine the clinical effectiveness and cost-effectiveness of an intervention to promote self-management, independence and self-efficacy in people with early-stage dementia. OBJECTIVES To undertake a randomised controlled trial of the Journeying through Dementia intervention compared with usual care, conduct an internal pilot testing feasibility, assess intervention delivery fidelity and undertake a qualitative exploration of participants' experiences. DESIGN A pragmatic two-arm individually randomised trial analysed by intention to treat. PARTICIPANTS A total of 480 people diagnosed with mild dementia, with capacity to make informed decisions, living in the community and not participating in other studies, and 350 supporters whom they identified, from 13 locations in England, took part. INTERVENTION Those randomised to the Journeying through Dementia intervention (n = 241) were invited to take part in 12 weekly facilitated groups and four one-to-one sessions delivered in the community by secondary care staff, in addition to their usual care. The control group (n = 239) received usual care. Usual care included drug treatment, needs assessment and referral to appropriate services. Usual care at each site was recorded. MAIN OUTCOME MEASURES The primary outcome was Dementia-Related Quality of Life score at 8 months post randomisation, with higher scores representing higher quality of life. Secondary outcomes included resource use, psychological well-being, self-management, instrumental activities of daily living and health-related quality of life. RANDOMISATION AND BLINDING Participants were randomised in a 1 : 1 ratio. Staff conducting outcome assessments were blinded. DATA SOURCES Outcome measures were administered in participants' homes at baseline and at 8 and 12 months post randomisation. Interviews were conducted with participants, participating carers and interventionalists. RESULTS The mean Dementia-Related Quality of Life score at 8 months was 93.3 (standard deviation 13.0) in the intervention arm (n = 191) and 91.9 (standard deviation 14.6) in the control arm (n = 197), with a difference in means of 0.9 (95% confidence interval -1.2 to 3.0; p = 0.380) after adjustment for covariates. This effect size (0.9) was less than the 4 points defined as clinically meaningful. For other outcomes, a difference was found only for Diener's Flourishing Scale (adjusted mean difference 1.2, 95% confidence interval 0.1 to 2.3), in favour of the intervention (i.e. in a positive direction). The Journeying through Dementia intervention cost £608 more than usual care (95% confidence interval £105 to £1179) and had negligible difference in quality-adjusted life-years (-0.003, 95% confidence interval -0.044 to 0.038). Therefore, the Journeying through Dementia intervention had a mean incremental cost per quality-adjusted life-year of -£202,857 (95% confidence interval -£534,733 to £483,739); however, there is considerable uncertainty around this. Assessed fidelity was good. Interviewed participants described receiving some benefit and a minority benefited greatly. However, negative aspects were also raised by a minority. Seventeen per cent of participants in the intervention arm and 15% of participants in the control arm experienced at least one serious adverse event. None of the serious adverse events were classified as related to the intervention. LIMITATIONS Study limitations include recruitment of an active population, delivery challenges and limitations of existing outcome measures. CONCLUSIONS The Journeying through Dementia programme is not clinically effective, is unlikely to be cost-effective and cannot be recommended in its existing format. FUTURE WORK Research should focus on the creation of new outcome measures to assess well-being in dementia and on using elements of the intervention, such as enabling enactment in the community. TRIAL REGISTRATION This trial is registered as ISRCTN17993825. 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. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gail Mountain
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Jessica Wright
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy L Cooper
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ellen Lee
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Research Unit, University of Nottingham, Nottingham, UK
| | | | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katherine Berry
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Tom Dening
- Division of Psychiatry & Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amanda Loban
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emily Turton
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Benjamin D Thomas
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma L Young
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Benjamin J Thompson
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Bethany Crawford
- Division of Psychiatry & Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Claire Craig
- Art and Design Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Peter Bowie
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | | | - Alexis Foster
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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13
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Mountain GA, Cooper CL, Wright J, Walters SJ, Lee E, Craig C, Berry K, Sprange K, Young T, Moniz-Cook E, Dening T, Loban A, Turton E, Beresford-Dent J, Thomas BD, Thompson BJ, Young EL. The Journeying through Dementia psychosocial intervention versus usual care study: a single-blind, parallel group, phase 3 trial. THE LANCET. HEALTHY LONGEVITY 2022; 3:e276-e285. [PMID: 36098301 DOI: 10.1016/s2666-7568(22)00059-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is an urgent clinical need for evidence-based psychosocial interventions for people with mild dementia. We aimed to determine the clinical benefits and cost-effectiveness of Journeying through Dementia (JtD), an intervention designed to promote wellbeing and independence in people with mild dementia. METHODS We did a single-blind, parallel group, individually randomised, phase 3 trial at 13 National Health Service sites across England. People with mild dementia (Mini-Mental State Examination score of ≥18) who lived in the community were eligible for inclusion. Patients were centrally randomly assigned (1:1) to receive the JtD intervention plus standard care (JtD group) or standard care only (standard care group). Randomisation was stratified by study site. The JtD intervention included 12 group and four one-to-one sessions, delivered in the community at each site. The primary endpoint was Dementia Related Quality of Life (DEMQOL) 8 months after randomisation, assessed according to the intention-to-treat principle. Only outcome assessors were masked to group assignment. A cost-effectiveness analysis reported cost per quality-adjusted life-year (QALY) from a UK NHS and social care perspective. The study is registered with ISRCTN, ISRCTN17993825. FINDINGS Between Nov 30, 2016, and Aug 31, 2018, 1183 patients were screened for inclusion, of whom 480 (41%) participants were randomly assigned: 241 (50%) to the JtD group and 239 (50%) to the standard care group. Intervention adherence was very good: 165 (68%) of 241 participants in the JtD group attended at least ten of the 16 sessions. Mean DEMQOL scores at 8 months were 93·3 (SD 13·0) for the JtD group and 91·9 (SD 14·6) for the control group. Difference in means was 0·9 (95% CI -1·2 to 3·0; p=0·38) after adjustment for covariates, lower than that identified as clinically meaningful. Incremental cost per QALY ranged from £88 000 to -£205 000, suggesting that JtD was not cost-effective. Unrelated serious adverse events were reported by 40 (17%) patients in the JtD group and 35 (15%) patients in the standard care group. INTERPRETATION In common with other studies, the JtD intervention was not proven effective. However, this complex trial successfully recruited and retained people with dementia without necessarily involving carers. Additionally, people with dementia were actively involved as participants and study advisers throughout. More research into methods of measuring small, meaningful changes in this population is needed. Questions remain regarding how services can match the complex, diverse, and individual needs of people with mild dementia, and how interventions to meet such needs can be delivered at scale. FUNDING UK National Institute of Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Gail A Mountain
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Cindy L Cooper
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Jessica Wright
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ellen Lee
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Claire Craig
- Art & Design Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Katherine Berry
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Esme Moniz-Cook
- Faculty of Health Sciences, The University of Hull, Hull, UK
| | - Tom Dening
- Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amanda Loban
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Emily Turton
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Benjamin D Thomas
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Emma L Young
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
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14
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Stathi A, Greaves CJ, Thompson JL, Withall J, Ladlow P, Taylor G, Medina-Lara A, Snowsill T, Gray S, Green C, Johansen-Berg H, Sexton CE, Bilzon JLJ, deKoning J, Bollen JC, Moorlock SJ, Western MJ, Demnitz N, Seager P, Guralnik JM, Rejeski WJ, Hillsdon M, Fox KR. Effect of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: the REACT (Retirement in Action) randomised controlled trial. Lancet Public Health 2022; 7:e316-e326. [PMID: 35325627 PMCID: PMC8967718 DOI: 10.1016/s2468-2667(22)00004-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mobility limitations in old age can greatly reduce quality of life, generate substantial health and social care costs, and increase mortality. Through the Retirement in Action (REACT) trial, we aimed to establish whether a community-based active ageing intervention could prevent decline in lower limb physical functioning in older adults already at increased risk of mobility limitation. METHODS In this pragmatic, multicentre, two-arm, single-blind, parallel-group, randomised, controlled trial, we recruited older adults (aged 65 years or older and who are not in full-time employment) with reduced lower limb physical functioning (Short Physical Performance Battery [SPPB] score 4-9) from 35 primary care practices across three sites (Bristol and Bath; Birmingham; and Devon) in England. Participants were randomly assigned to receive brief advice (three healthy ageing education sessions) or a 12-month, group-based, multimodal physical activity (64 1-h exercise sessions) and behavioural maintenance (21 45-min sessions) programme delivered by charity and community or leisure centre staff in local communities. Randomisation was stratified by site and adopted a minimisation approach to balance groups by age, sex, and SPPB score, using a centralised, online, randomisation algorithm. Researchers involved in data collection and analysis were masked but participants were not because of the nature of the intervention. The primary outcome was change in SPPB score at 24 months, analysed by intention to treat. This trial is registered with ISRCTN, ISRCTN45627165. FINDINGS Between June 20, 2016, and Oct 30, 2017, 777 participants (mean age 77·6 [SD 6·8] years; 66% female; mean SPPB score 7·37 [1·56]) were randomly assigned to the intervention (n=410) and control (n=367) groups. Primary outcome data at 24 months were provided by 628 (81%) participants (294 in the control group and 334 in the intervention group). At the 24-month follow-up, the SPPB score (adjusted for baseline SPPB score, age, sex, study site, and exercise group) was significantly greater in the intervention group (mean 8·08 [SD 2·87]) than in the control group (mean 7·59 [2·61]), with an adjusted mean difference of 0·49 (95% CI 0·06-0·92; p=0·014), which is just below our predefined clinically meaningful difference of 0·50. One adverse event was related to the intervention; the most common unrelated adverse events were heart conditions, strokes, and falls. INTERPRETATION For older adults at risk of mobility limitations, the REACT intervention showed that a 12-month physical activity and behavioural maintenance programme could help prevent decline in physical function over a 24-month period. FUNDING National Institute for Health Research Public Health Research Programme (13/164/51).
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Affiliation(s)
- Afroditi Stathi
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.
| | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Janice L Thompson
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Janet Withall
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK; Department for Health, University of Bath, Bath, UK
| | - Peter Ladlow
- Academic Department of Military Rehabilitation (ADMR), Defence Medical Rehabilitation Centre (DMRC), Stanford Hall, Loughborough, UK
| | - Gordon Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Tristan Snowsill
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Selena Gray
- Faculty of Health and Applied Sciences, University of the West of England (UWE) Bristol, Bristol, UK
| | - Colin Green
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Heidi Johansen-Berg
- Oxford Centre for Functional MRI of the Brain, Wellcome Centre for Integrative Neuroimaging, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Claire E Sexton
- Oxford Centre for Human Brain Activity, Wellcome Centre for Integrative Neuroimaging, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Global Brain Health Institute, Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Jessica C Bollen
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sarah J Moorlock
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Naiara Demnitz
- Danish Research Centre for Magnetic Resonance, Centre for Functional Diagnostic Imaging and Research, Copenhagen University Hospital -Amager and Hvidovre, Hvidovre, Denmark
| | - Poppy Seager
- Oxford Centre for Functional MRI of the Brain, Wellcome Centre for Integrative Neuroimaging, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - W Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA
| | - Melvyn Hillsdon
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Kenneth R Fox
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
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15
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Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial. Eur Child Adolesc Psychiatry 2021; 30:699-710. [PMID: 32388627 DOI: 10.1007/s00787-020-01551-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.
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16
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Chan CL, Smuk M, Sohanpal R, Pinnock H, Taylor SJC. Tailored, psychological intervention for anxiety and/or depression in people with chronic obstructive pulmonary disease (COPD), TANDEM (Tailored intervention for ANxiety and DEpression Management in COPD): statistical analysis plan for a randomised controlled trial. Trials 2020; 21:858. [PMID: 33059755 PMCID: PMC7559776 DOI: 10.1186/s13063-020-04786-1] [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] [Received: 04/20/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022] Open
Abstract
Background The aim of the TANDEM trial is to evaluate whether a tailored, psychological cognitive behavioural approach intervention, which links into, and optimises the effects of routine pulmonary rehabilitation (PR), leads to a reduction in mild/moderate anxiety and/or depression in people with moderate, severe or very severe chronic obstructive pulmonary disease. Methods and design TANDEM is a multi-centre, two-arm, parallel group, pragmatic, individually randomised controlled, superiority trial including an internal pilot. Participants are randomised to receive either the intervention (a tailored psychological intervention plus usual care including referral to PR) or the control (usual care including referral to PR). The designed randomisation ratio is 1.25:1 in favour of the intervention. The multiple-primary outcomes are participant depression and anxiety at 6 months, measured using the Hospital Anxiety and Depression Scale (HADS) depression and anxiety subscales. Results This article describes the statistical analysis plan (SAP) for the TANDEM trial. In particular, we describe the general analysis principles, how we will handle missing data, the primary and secondary outcomes and how these will be analysed, sensitivity analyses for the multiple-primary outcomes, and any other analyses and data summaries. The SAP was developed and published prior to completion of follow-up of the last participant. Trial registration ISRCTN registry ISRCTN59537391. Registered on 20 March 2017.
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Affiliation(s)
- Claire L Chan
- Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
| | - Melanie Smuk
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Ratna Sohanpal
- Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute, The University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Stephanie J C Taylor
- Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
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17
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Taylor PJ, Playle R, Robling M, Bezeczky Z, John-Evans H, Dimitropoulou P, McNamara R, Moriarty Y, Summers Z, Bagshaw R. A randomized controlled trial of a Group psychological intervention to increase locus of control for alcohol consumption among Alcohol-Misusing Short-term (male) Prisoners (GASP). Addiction 2020; 115:1844-1854. [PMID: 32045077 DOI: 10.1111/add.15006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 02/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Reducing alcohol misuse by male prisoners is an important global issue. Control of drinking behaviour could be a useful target for intervention in this population, and locus of control could be a causal factor in this. We aimed to assess the effect of a clinical psychologist-facilitated group intervention on male prisoners' locus of control of drinking behaviour. DESIGN A two-arm, single-site, open, randomized controlled trial. SETTING A category B local training prison in South Wales, housing about 770 mainly sentenced men. PARTICIPANTS Prisoners serving less than 2 years who met inclusion criteria for pre-imprisonment alcohol misuse, alone or with drug misuse. A total of 119 were allocated to the intervention arm and 119 to the control arm; 104 and 87, respectively, completed the post-randomization baseline interview and 68 and 60 completed a second interview approximately 4 weeks later, respectively, after intervention or treatment as usual (TAU) alone. INTERVENTION Nine clinical psychologist-facilitated groups in the prison over 3 weeks. Range of participants per session was one to seven, with three to five most usual. MEASURES The primary outcome was locus of control of behaviour (LCB); secondary outcomes included mental state generally (comprehensive psychiatric rating scale/CPRS) and specifically (Beck Depression Inventory/BDI). An integral process evaluation was conducted. FINDINGS LCB scores decreased during the study, but without significant intervention effect [-1.7, 95% confidence interval (CI) = -5.1 to 1.6, P = 0.329]. Change among completers in the control group was from a mean score of 37.4 [standard deviation (SD) = 10.0] to 33.7[SD = 11.7] and in the intervention group from 37.4 (SD = 11.6) to 31.9 (SD = 11.8). Secondary outcomes, including change in mental state, did not differ between arms, but 686 (64%) sessions were lost, most because of 'prison issues'. CONCLUSIONS A clinical psychologist-facilitated group intervention did not have a statistically significant effect on sense of control of drinking behaviour among men with pre-imprisonment alcohol misuse serving less than 2 years in a South Wales prison. The study proved coterminous, however, with 40% prison staff cuts which seem likely to have contributed to the high loss of group sessions and possibly overwhelmed any treatment effect. Intervention completion failures, previously cited as harmful, had no effect here, so the trial should be repeated when the prison climate improves.
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Affiliation(s)
- Pamela J Taylor
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Rebecca Playle
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Zoe Bezeczky
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Hannah John-Evans
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Zelda Summers
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Ruth Bagshaw
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
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18
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Dow DE, Mmbaga BT, Gallis JA, Turner EL, Gandhi M, Cunningham CK, O'Donnell KE. A group-based mental health intervention for young people living with HIV in Tanzania: results of a pilot individually randomized group treatment trial. BMC Public Health 2020; 20:1358. [PMID: 32887558 PMCID: PMC7487650 DOI: 10.1186/s12889-020-09380-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Increasing numbers of young people living with HIV (YPLWH) have unaddressed mental health challenges. Such challenges are associated with poor antiretroviral therapy (ART) adherence and high mortality. Few evidence-based mental health interventions exist to improve HIV outcomes among YPLWH. METHODS This pilot group treatment trial individually randomized YPLWH from two clinical sites in Tanzania, evaluated acceptability, feasibility, and preliminary effectiveness of a mental health intervention, Sauti ya Vijana (SYV; The Voice of Youth), was compared to the local standard-of-care (SOC) for improving ART adherence and virologic suppression. Enrolled YPLWH were 12-24 years of age and responded to mental health and stigma questionnaires, self-reported adherence, objective adherence measures (ART concentration in hair), and HIV RNA at baseline and 6-months (post-intervention). Feasibility and acceptability were evaluated, and potential effectiveness was assessed by comparing outcomes between arms using mixed effects modeling. RESULTS Between June 2016 and July 2017, 128 YPLWH enrolled; 105 were randomized and 93 (55 in SYV) followed-up at 6-months and were thereby included in this analysis. Mean age was 18.1 years; 51% were female; and 84% were HIV-infected perinatally. Attendance to intervention sessions was 86%; 6-month follow-up was 88%, and fidelity to the protocol approached 100%. Exploratory analyses of effectiveness demonstrated self-reported adherence improved by 7.3 percentage points (95% CI: 2.2, 12.3); and the pooled standard deviation for all ART concentration values increased by 0.17 units (95% CI: - 0.52, 0.85) in the SYV arm compared to SOC. Virologic suppression rates (HIV RNA < 400 copies/mL) at baseline were 65% in both arms but increased to 75% in the SYV arm while staying the same in the SOC arm (RR 1.13; 95% CI: 0.94, 1.36). CONCLUSIONS YPLWH often have poor HIV outcomes, making interventions to improve outcomes in this population critical. This pilot trial of the Tanzania-based SYV intervention demonstrated trends towards improvement in ART adherence and virologic outcomes among YPLWH, supporting efforts to scale the intervention into a fully-powered effectiveness trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02888288 . Registered August 9, 2016. Retrospectively registered as first participant enrolled June 16, 2016.
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Affiliation(s)
- Dorothy E Dow
- Duke University Medical Center, Pediatrics, Infectious Diseases, Box 3499, Durham, NC, 27710, USA. .,Duke Global Health Institute, Durham, NC, USA. .,Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Blandina T Mmbaga
- Duke Global Health Institute, Durham, NC, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - John A Gallis
- Duke Global Health Institute, Durham, NC, USA.,Duke University, Department of Biostatistics and Bioinformatics, Durham, NC, USA
| | - Elizabeth L Turner
- Duke Global Health Institute, Durham, NC, USA.,Duke University, Department of Biostatistics and Bioinformatics, Durham, NC, USA
| | | | - Coleen K Cunningham
- Duke University Medical Center, Pediatrics, Infectious Diseases, Box 3499, Durham, NC, 27710, USA.,Duke Global Health Institute, Durham, NC, USA
| | - Karen E O'Donnell
- Duke University, Center for Health Policy and Inequalities Research, Durham, NC, USA.,Center for Child and Family Health, Durham, NC, USA
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Sinclair K, Carty C, Gonzales K, Nikolaus C, Gillespie L, Buchwald D. Strong Men, Strong Communities: Design of a Randomized Controlled Trial of a Diabetes Prevention Intervention for American Indian and Alaska Native Men. Am J Mens Health 2020; 14:1557988320945457. [PMID: 32757825 PMCID: PMC7412907 DOI: 10.1177/1557988320945457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 01/04/2023] Open
Abstract
Type 2 diabetes is a serious global epidemic that disproportionately affects disadvantaged populations. American Indians and Alaska Natives (AIs/ANs) have the highest rates of diabetes in the nation with a prevalence of 14.7% in 2018, more than twice that of non-Hispanic Whites. AI/AN men have the highest prevalence of diagnosed type 2 diabetes (14.5%) compared to non-Hispanic Black (11.4%), non-Hispanic Asian (10.0%), and non-Hispanic White (8.6%) men. Several landmark clinical trials have shown that lifestyle interventions can effectively prevent or delay the onset of diabetes among those at risk, including in AIs/ANs. Despite positive outcomes for AIs/ANs in these studies, very few were men. To date, there have been no concerted efforts to recruit and retain AI/AN men in interventions that promote weight loss and healthy lifestyles to prevent diabetes, and they remain underrepresented in these types of studies. This article describes the design and methods of the first randomized controlled trial of a diabetes prevention program with a study sample comprised entirely of AI/AN men. Research to date has demonstrated suboptimal patterns of recruitment and retention of AI/AN men, resulting in their virtual absence in health and intervention research. Effective methods to recruit and retain AI/AN men, and potential benefit gained from participation in diabetes prevention research, are unknown for this population who experience a high prevalence of type 2 diabetes. The study design presented in this article offers promising insights to help remedy these important shortcomings in the science of recruitment and retention of AI/AN men in research.
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Affiliation(s)
- Ka‘imi Sinclair
- College of Nursing, Initiative for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA
| | - Cara Carty
- Initiative for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA
| | - Kelly Gonzales
- Portland State University-Oregon Health Sciences University Joint School of Public Health, Portland, OR, USA
| | - Cassandra Nikolaus
- Initiative for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA
| | - Lucas Gillespie
- Initiative for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA
| | - Dedra Buchwald
- Initiative for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA
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20
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Beck E, Bo S, Jørgensen MS, Gondan M, Poulsen S, Storebø OJ, Fjellerad Andersen C, Folmo E, Sharp C, Pedersen J, Simonsen E. Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial. J Child Psychol Psychiatry 2020; 61:594-604. [PMID: 31702058 DOI: 10.1111/jcpp.13152] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Borderline personality disorder (BPD) typically onsets in adolescence and predicts later functional disability in adulthood. Highly structured evidence-based psychotherapeutic programs, including mentalization-based treatment (MBT), are first choice treatment. The efficacy of MBT for BPD has mainly been tested with adults, and no RCT has examined the effectiveness of MBT in groups (MBT-G) for adolescent BPD. METHOD A total of 112 adolescents (111 females) with BPD (106) or BPD symptoms ≥4 DSM-5 criteria (5) referred to child and adolescent psychiatric outpatient clinics were randomized to a 1-year MBT-G, consisting of three introductory, psychoeducative sessions, 37 weekly group sessions, five individual case formulation sessions, and six group sessions for caregivers, or treatment as usual (TAU) with at least 12 monthly individual sessions. The primary outcome was the score on the borderline personality features scale for children (BPFS-C); secondary outcomes included self-harm, depression, externalizing and internalizing symptoms (all self-report), caregiver reports, social functioning, and borderline symptoms rated by blinded clinicians. Outcome assessments were made at baseline, after 10, 20, and 30 weeks, and at end of treatment (EOT). The ClinicalTrials.gov identifier is NCT02068326. RESULTS At EOT, the primary outcome was 71.3 (SD = 15.0) in the MBT-G group and 71.3 (SD = 15.2) in the TAU group (adjusted mean difference 0.4 BPFS-C units in favor of MBT-G, 95% confidence interval -6.3 to 7.1, p = .91). No significant group differences were found in the secondary outcomes. 29% in both groups remitted. 29% of the MBT group completed less than half of the sessions compared with 7% of the control group. CONCLUSIONS There is no indication for superiority of either therapy method. The low remission rate points to the importance of continued research into early intervention. Specifically, retention problems need to be addressed.
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Affiliation(s)
- Emma Beck
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Sune Bo
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Mie Sedoc Jørgensen
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Matthias Gondan
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Espen Folmo
- Norwegian National Advisory Unit on Personality Psychiatry, Oslo University Hospital, Oslo, Norway
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, TX, USA.,Center for Development Support, University of the Free State, Bloemfontein, South Africa
| | - Jesper Pedersen
- Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Biggs K, Hind D, Gossage-Worrall R, Sprange K, White D, Wright J, Chatters R, Berry K, Papaioannou D, Bradburn M, Walters SJ, Cooper C. Challenges in the design, planning and implementation of trials evaluating group interventions. Trials 2020; 21:116. [PMID: 31996259 PMCID: PMC6990578 DOI: 10.1186/s13063-019-3807-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background Group interventions are interventions delivered to groups of people rather than to individuals and are used in healthcare for mental health recovery, behaviour change, peer support, self-management and/or health education. Evaluating group interventions in randomised controlled trials (RCTs) presents trialists with a set of practical problems, which are not present in RCTs of one-to-one interventions and which may not be immediately obvious. Methods Case-based approach summarising Sheffield trials unit’s experience in the design and implementation of five group interventions. We reviewed participant recruitment and attrition, facilitator training and attrition, attendance at the group sessions, group size and fidelity aspects across five RCTs. Results Median recruitment across the five trials was 3.2 (range 1.7–21.0) participants per site per month. Group intervention trials involve a delay in starting the intervention for some participants, until sufficient numbers are available to start a group. There was no evidence that the timing of consent, relative to randomisation, affected post-randomisation attrition which was a matter of concern for all trial teams. Group facilitator attrition was common in studies where facilitators were employed by the health system rather than the by the grant holder and led to the early closure of one trial; research sites responded by training ‘back-up’ and new facilitators. Trials specified that participants had to attend a median of 62.5% (range 16.7%–80%) of sessions, in order to receive a ‘therapeutic dose’; a median of 76.7% (range 42.9%–97.8%) received a therapeutic dose. Across the five trials, 75.3% of all sessions went ahead without the pre-specified ideal group size. A variety of methods were used to assess the fidelity of group interventions at a group and individual level across the five trials. Conclusion This is the first paper to provide an empirical basis for planning group intervention trials. Investigators should expect delays/difficulties in recruiting groups of the optimal size, plan for both facilitator and participant attrition, and consider how group attendance and group size affects treatment fidelity. Trial registration ISRCTN17993825 registered on 11/10/2016, ISRCTN28645428 registered on 11/04/2012, ISRCTN61215213 registered on 11/05/2011, ISRCTN67209155 registered on 22/03/2012, ISRCTN19447796 registered on 20/03/2014.
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Affiliation(s)
- Katie Biggs
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Daniel Hind
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Rebecca Gossage-Worrall
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - David White
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Jessica Wright
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Robin Chatters
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Katherine Berry
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Diana Papaioannou
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Cindy Cooper
- School of Health and Related Research (ScHARR) University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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Barker A, Cameron P, Flicker L, Arendts G, Brand C, Etherton-Beer C, Forbes A, Haines T, Hill AM, Hunter P, Lowthian J, Nyman SR, Redfern J, Smit DV, Waldron N, Boyle E, MacDonald E, Ayton D, Morello R, Hill K. Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the emergency department with a fall: A randomised controlled trial. PLoS Med 2019; 16:e1002807. [PMID: 31125354 PMCID: PMC6534288 DOI: 10.1371/journal.pmed.1002807] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/12/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Falls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program-RESPOND-had an effect on falls and fall injuries in older people presenting to the ED after a fall. METHODS AND FINDINGS Community-dwelling people aged 60-90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis-217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43-0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51-1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15-0.91]; P = 0.03), but there were no significant differences in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy, and quality of life. There were two deaths in the RESPOND group and one in the control group. No adverse events or unintended harm were reported. Limitations of this study were the high number of dropouts (n = 93); possible underreporting of falls, fall injuries, and hospitalisations across both groups; and the relatively small number of fracture events. CONCLUSIONS In this study, providing a telephone-based, patient-centred falls prevention program reduced falls but not fall injuries, in older people presenting to the ED with a fall. Among secondary outcomes, only fractures reduced. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending the ED. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).
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Affiliation(s)
- Anna Barker
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Leon Flicker
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Glenn Arendts
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Caroline Brand
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Melbourne EpiCentre, University of Melbourne, Melbourne, Victoria, Australia
- Melbourne EpiCentre, Melbourne Health, Melbourne, Victoria, Australia
| | - Christopher Etherton-Beer
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
- Allied Health Research Unit, Monash Health, Melbourne, Victoria, Australia
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | | | - Judy Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| | - Samuel R. Nyman
- Department of Psychology and Ageing & Dementia Research Centre, Faculty of Science and Technology, Bournemouth University, Poole, United Kingdom
| | - Julie Redfern
- Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
| | | | - Nicholas Waldron
- Health Networks Branch, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia
| | - Eileen Boyle
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Ellen MacDonald
- Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- * E-mail:
| | - Renata Morello
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Keith Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
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Moriarty Y, Townson J, Quinn-Scoggins H, Padgett L, Owen S, Smits S, Playle R, Dimitropoulou P, Sewell B, Kolovou V, Buckle P, Carter B, Edwards A, Hepburn J, Matthews M, Mitchell C, Neal RD, Robling M, Wood F, Brain K. Improving cancer symptom awareness and help-seeking among adults living in socioeconomically deprived communities in the UK using a facilitated health check: A protocol for the Awareness and Beliefs About Cancer (ABACus) Randomised Control Trial. BMC Public Health 2019; 19:285. [PMID: 30866887 PMCID: PMC6417119 DOI: 10.1186/s12889-019-6612-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/28/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cancer survival is lower in socioeconomically deprived communities, partly due to low awareness of symptoms, negative beliefs and delayed help-seeking. We developed an interactive health check questionnaire facilitated by trained lay advisors. It entails 29 questions about background, lifestyle and health with tailored behaviour change advice. Personalised results are printed using a traffic light (red/amber/green) system, highlighting areas where action should be taken. This is an individually randomised control trial to test effectiveness of the health check on symptom recognition. METHODS A total 246 participants aged 40+ years will be recruited from community and healthcare settings in socioeconomically deprived areas of Yorkshire and South Wales. Participants will be randomised to receive the health check or standard care (1:1 ratio). Outcome measures include: adapted Awareness and Beliefs about Cancer (primary outcome), brief State Trait Anxiety Inventory, intentions and motivation to adopt recommended health behaviours (early symptom presentation, cancer screening and lifestyle behaviours), adapted Client Service Receipt Inventory, brief medical history/screening and demographic questionnaire at: baseline; 2-weeks; and 6-months post-randomisation. A purposive sample of intervention sessions will be audio-recorded (n = 24) and half will additionally be observed (n = 12). Semi-structured interviews will take place at 2-weeks (n = 30) and 6-months (n = 15-20) post-randomisation. The primary analysis will compare cancer symptom recognition scores between arms at 2-weeks. Secondary analysis will assess cancer beliefs, barriers/time to presentation, screening and lifestyle behaviours, anxiety and costs. A process evaluation will assess intervention fidelity, dose and contamination. The London-Surrey NHS Research Ethics Committee (Ref: 17/LO/1507) approved this trial. DISCUSSION This is a trial of a theoretically underpinned complex intervention which has undergone phase 1 and 2 development work. The findings will evaluate evidence about the effect of the health check on symptom awareness. Although there are few exclusion criteria there are limitations regarding the population we are able to reach, who may have even higher risks of late diagnosis and poor cancer prognosis. However, the health check has the potential to improve cancer symptom awareness and encourage early help-seeking behaviour in deprived populations, thereby reducing inequalities in longer term cancer outcomes. TRIAL REGISTRATION Retrospectively registered with ISRCTN (Ref: ISRCTN16872545 ) on 12.01.2018.
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Affiliation(s)
- Yvonne Moriarty
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Julia Townson
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Harriet Quinn-Scoggins
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Louise Padgett
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Sioned Owen
- Tenovus Cancer Care, Gleider House, Ty-Glas Rd, Cardiff, CF14 5BD UK
| | - Stephanie Smits
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Rebecca Playle
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Polyxeni Dimitropoulou
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Bernadette Sewell
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Vasiliki Kolovou
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Peter Buckle
- Marie Curie Research Voices, Marie Curie, 89 Albert Embankment, London, SE1 7TP UK
| | - Ben Carter
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Julie Hepburn
- Public Involvement Community, Health and Care Research Wales support Centre, Castlebridge 4, 15-19, Cowbridge Road East, Cardiff, CF11 9AB UK
| | - Maura Matthews
- Tenovus Cancer Care, Gleider House, Ty-Glas Rd, Cardiff, CF14 5BD UK
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, University of Sheffield, Northern General Hospital, Sheffield, S5 7AU UK
| | - Richard D Neal
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL UK
| | - Michael Robling
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Fiona Wood
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
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Forster DA, McLardie-Hore FE, McLachlan HL, Davey MA, Grimes HA, Dennis CL, Mortensen K, Moorhead AM, Tawia S, Gold L, Shafiei T, Small R, East CE, Amir LH. Proactive Peer (Mother-to-Mother) Breastfeeding Support by Telephone (Ringing up About Breastfeeding Early [RUBY]): A Multicentre, Unblinded, Randomised Controlled Trial. EClinicalMedicine 2019; 8:20-28. [PMID: 31193656 PMCID: PMC6537529 DOI: 10.1016/j.eclinm.2019.02.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Breastfeeding rates are suboptimal internationally, and many infants are not receiving any breast milk at all by six months of age. Few interventions increase breastfeeding duration, particularly where there is relatively high initiation. The effect of proactive peer (mother-to-mother) support has been found to increase breastfeeding in some contexts but not others, but if it is shown to be effective would be a potentially sustainable model in many settings. We aimed to determine whether proactive telephone-based peer support during the postnatal period increases the proportion of infants being breastfed at six months of age. METHODS RUBY (Ringing Up about Breastfeeding earlY) was a multicentre, two-arm un-blinded randomised controlled trial conducted in three hospitals in Victoria, Australia. First-time mothers intending to breastfeed were recruited after birth and prior to hospital discharge, and randomly assigned (1:1) to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum. A computerised random number program generated block sizes of four or six distributed randomly, with stratification by site. Research midwives were masked to block size, but masking of allocation was not possible. The primary outcome was the proportion of infants receiving any breast milk at six months of age. Analyses were by intention to treat; data were collected and analysed masked to group. The trial is registered with ACTRN, number 12612001024831. FINDINGS Women were recruited between Feb 14, 2013 and Dec 15, 2015 and randomly assigned to peer support (n = 574) or usual care (n = 578). Five were not in the primary analysis [5 post-randomisation exclusions]. Infants of women allocated to telephone-based peer support were more likely than those allocated to usual care to be receiving breast milk at six months of age (intervention 75%, usual care 69%; Adj. RR 1·10; 95% CI 1·02, 1·18). There were no adverse events. INTERPRETATION Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation. FUNDING The Felton Bequest, Australia, philanthropic donation and La Trobe University grant.
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Key Words
- ABA, Australian Breastfeeding Association
- ACTRN, Australian New Zealand Clinical Trials Registry number
- AUD, Australian dollar(s)
- Adj. RR, Adjusted relative risk
- Breastfeeding
- CI, Confidence interval
- Clinical trial
- Community-based
- HR, Hazard ratio
- Peer support
- Peer volunteer
- RCT, Randomised controlled trial
- RR, Relative risk
- RUBY, Ringing Up about Breastfeeding earlY
- Telephone intervention
- sd, Standard deviation
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Affiliation(s)
- Della A. Forster
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
- Royal Women's Hospital, 20 Flemington Rd, Parkville, Victoria 3052, Australia
- Corresponding author at: Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia.
| | - Fiona E. McLardie-Hore
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
- Royal Women's Hospital, 20 Flemington Rd, Parkville, Victoria 3052, Australia
| | - Helen L. McLachlan
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
- School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
| | - Mary-Ann Davey
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Rd, Clayton 3168, Australia
| | - Heather A. Grimes
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
| | - Cindy-Lee Dennis
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario M5T 1P8, Canada
| | - Kate Mortensen
- Monash Nursing and Midwifery, Monash University and Monash Health, Australia
| | - Anita M. Moorhead
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
- Royal Women's Hospital, 20 Flemington Rd, Parkville, Victoria 3052, Australia
| | - Susan Tawia
- Australian Breastfeeding Association, Level 3, Suite 2,150 Albert Road, South Melbourne, Victoria 3205, Australia
| | - Lisa Gold
- School of Health and Social Development, Deakin University, Geelong, Victoria 3220, Australia
| | - Touran Shafiei
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
| | - Rhonda Small
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
| | - Christine E. East
- Monash Nursing and Midwifery, Monash University and Monash Health, Australia
| | - Lisa H. Amir
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia
- Royal Women's Hospital, 20 Flemington Rd, Parkville, Victoria 3052, Australia
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Musa MK, Vinsnes AG, Blekken LE, Harris RG, Goodman C, Boyers D, Norton C. Interventions for treating or managing faecal incontinence in older people living in care homes. Hippokratia 2018. [DOI: 10.1002/14651858.cd013200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Massirfufulay K Musa
- King’s College London; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care; 57 Waterloo Road London UK SE1 8WA
| | - Anne G Vinsnes
- Norwegian University of Science and Technology; Department of Public Health and Nursing; Mauritz Hansens gt 2 Trondheim Norway N-7491
| | - Lene Elisabeth Blekken
- Norwegian University of Science and Technology; Department of Public Health and Nursing; Mauritz Hansens gt 2 Trondheim Norway N-7491
| | - Ruth G Harris
- King’s College London; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care; 57 Waterloo Road London UK SE1 8WA
| | - Claire Goodman
- University of Hertfordshire; Centre for Research in Primary and Community Care; Hertfordshire UK AL10 9AB
| | - Dwayne Boyers
- University of Aberdeen; Health Economics Research Unit; Polwarth Building Foresterhill Aberdeen UK AB25 2ZD
| | - Christine Norton
- King’s College London; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care; 57 Waterloo Road London UK SE1 8WA
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Candlish J, Teare MD, Dimairo M, Flight L, Mandefield L, Walters SJ. Appropriate statistical methods for analysing partially nested randomised controlled trials with continuous outcomes: a simulation study. BMC Med Res Methodol 2018; 18:105. [PMID: 30314463 PMCID: PMC6186141 DOI: 10.1186/s12874-018-0559-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 09/18/2018] [Indexed: 11/12/2022] Open
Abstract
Background In individually randomised trials we might expect interventions delivered in groups or by care providers to result in clustering of outcomes for participants treated in the same group or by the same care provider. In partially nested randomised controlled trials (pnRCTs) this clustering only occurs in one trial arm, commonly the intervention arm. It is important to measure and account for between-cluster variability in trial design and analysis. We compare analysis approaches for pnRCTs with continuous outcomes, investigating the impact on statistical inference of cluster sizes, coding of the non-clustered arm, intracluster correlation coefficient (ICCs), and differential variance between intervention and control arm, and provide recommendations for analysis. Methods We performed a simulation study assessing the performance of six analysis approaches for a two-arm pnRCT with a continuous outcome. These include: linear regression model; fully clustered mixed-effects model with singleton clusters in control arm; fully clustered mixed-effects model with one large cluster in control arm; fully clustered mixed-effects model with pseudo clusters in control arm; partially nested homoscedastic mixed effects model, and partially nested heteroscedastic mixed effects model. We varied the cluster size, number of clusters, ICC, and individual variance between the two trial arms. Results All models provided unbiased intervention effect estimates. In the partially nested mixed-effects models, methods for classifying the non-clustered control arm had negligible impact. Failure to account for even small ICCs resulted in inflated Type I error rates and over-coverage of confidence intervals. Fully clustered mixed effects models provided poor control of the Type I error rates and biased ICC estimates. The heteroscedastic partially nested mixed-effects model maintained relatively good control of Type I error rates, unbiased ICC estimation, and did not noticeably reduce power even with homoscedastic individual variances across arms. Conclusions In general, we recommend the use of a heteroscedastic partially nested mixed-effects model, which models the clustering in only one arm, for continuous outcomes similar to those generated under the scenarios of our simulations study. However, with few clusters (3–6), small cluster sizes (5–10), and small ICC (≤0.05) this model underestimates Type I error rates and there is no optimal model. Electronic supplementary material The online version of this article (10.1186/s12874-018-0559-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jane Candlish
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - M Dawn Teare
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Munyaradzi Dimairo
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Laura Mandefield
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
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27
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Axford N, Warner G, Hobbs T, Heilmann S, Raja A, Berry V, Ukoumunne OC, Matthews J, Eames T, Kallitsoglou A, Blower S, Wilkinson T, Timmons L, Bjornstad G. The effectiveness of the Inspiring Futures parenting programme in improving behavioural and emotional outcomes in primary school children with behavioural or emotional difficulties: study protocol for a randomised controlled trial. BMC Psychol 2018; 6:3. [PMID: 29458423 PMCID: PMC5819163 DOI: 10.1186/s40359-018-0214-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a need to build the evidence base of early interventions promoting children's health and development in the UK. Malachi Specialist Family Support Services ('Malachi') is a voluntary sector organisation based in the UK that delivers a therapeutic parenting group programme called Inspiring Futures to parents of children identified as having behavioural and emotional difficulties. The programme comprises two parts, delivered sequentially: (1) a group-based programme for all parents for 10-12 weeks, and (2) one-to-one sessions with selected parents from the group-based element for up to 12 weeks. METHODS/DESIGN A randomised controlled trial will be conducted to evaluate Malachi's Inspiring Futures parenting programme. Participants will be allocated to one of two possible arms, with follow-up measures at 16 weeks (post-parent group programme) and at 32 weeks (post-one-to-one sessions with selected parents). The sample size is 248 participants with a randomisation allocation ratio of 1:1. The intervention arm will be offered the Inspiring Futures programme. The control group will receive services as usual. The aim is to determine the effectiveness of the Inspiring Futures programme on the primary outcome of behavioural and emotional difficulties of primary school children identified as having behavioural or emotional difficulties. DISCUSSION This study will further enhance the evidence for early intervention parenting programmes for child behavioural and emotional problems in the UK. TRIAL REGISTRATION Current Controlled Trials ISRCTN32083735 . Retrospectively registered 28 October 2014.
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Affiliation(s)
- Nick Axford
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Plymouth University Peninsula Schools of Medicine and Dentistry, ITTC, Plymouth Science Park, Plymouth, PL6 8BX, UK.
| | - Georgina Warner
- Autistica, St Saviour's House, 39-41 Union Street, London, SE1 1SD, UK
| | - Tim Hobbs
- Dartington Service Design Lab, Lower Hood Barn, Dartington, TQ9 6AB, UK
| | - Sarah Heilmann
- Department of Public Administration and Sociology, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Mandeville Building, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, T16-37, The Netherlands
| | - Anam Raja
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Vashti Berry
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Justin Matthews
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Tim Eames
- Exeter Clinical Trials Support Network, Royal Devon & Exeter Foundation NHS Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Angeliki Kallitsoglou
- School of Education, University of Roehampton, Roehampton Lane, London, SW15 5PJ, UK
| | - Sarah Blower
- Department of Health Sciences, University of York, Area 2 ATB/152 Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK
| | - Tom Wilkinson
- Torbay Depression and Anxiety Service, 266 Torquay Road, Paignton, TQ3 2EZ, UK
| | - Luke Timmons
- RSA (Royal Society for the encouragement of Arts, Manufactures and Commerce), 8 John Adam Street, London, WC2N 6EZ, UK
| | - Gretchen Bjornstad
- Peninsula Cerebra Research Unit (PenCRU), University of Exeter Medical School, St. Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
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