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Hassani S, Bou Dargham T, Cantrell S, Ikramuddin S, Feng W. Minorities are under-reported and females are under-represented in stroke motor recovery trials. Top Stroke Rehabil 2024:1-5. [PMID: 39074068 DOI: 10.1080/10749357.2024.2384324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 07/21/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Inclusion of diverse patient populations in stroke rehabilitation clinical trials is key for generalizability and detecting differences in subgroups. The aim of this study was to assess the reporting and inclusion of race, ethnicity, and sex in publications in post-stroke motor recovery clinical trials over the past 5 years. METHODS We conducted a systematic review of stroke motor recovery trials conducted only within the United States with at least one control group and published between 2019 and 2023. The percent of racial minorities, ethnicities, and women enrolled in the trials was extracted and calculated for those trials using available data found in the manuscript or on clinicaltrials.gov. RESULTS Sixty-eight trials (total of 2,801 participants) met the inclusion criteria and were included in the analysis. 100%, 35%, and 21% of the trials included reported enrollment by sex, race, and ethnicity in the manuscript. All publications reported sex and 38% of the subjects were female. Among the trials reporting race, 59% of the participants were White, followed by 34% Black, 0.4% Native American, 4% Asian, and 3% Other. Among the trials that reported ethnicity, Hispanic or Latino participants were represented as 13% of the total participants. CONCLUSIONS In the past 5 years, while all stroke rehab trial publications reported data on sex, they underrepresented women. Most publications did not report race or ethnicity. Improvement in reporting of race/ethnicity in stroke motor recovery trials is needed for understanding of progress with inclusion, and improvement in inclusion of women is needed for better generalizability.
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Affiliation(s)
- Sara Hassani
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Tarek Bou Dargham
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Sarah Cantrell
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Salman Ikramuddin
- Department of Neurology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
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Mehrabi S, Harnett A, Saikaley M, Fleet JL, Eng JJ, Bayley M, Teasell R. Female Enrollment in Rehabilitation Trials: A Systematic Review of Reporting Sex and Female Participation in Randomized Controlled Trials of Poststroke Upper Extremity Rehabilitation Over 50 Years. Arch Phys Med Rehabil 2024; 105:1399-1406. [PMID: 38367832 DOI: 10.1016/j.apmr.2024.01.026] [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: 11/02/2023] [Revised: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVE To systematically assess the reporting of sex and the percentage of female participants in randomized controlled trials (RCTs) examining interventions for the post-stroke rehabilitation of upper extremity (UE) motor disorders. DATA SOURCES CINAHL, Embase, PubMed, Scopus and Web of Science were searched from 1960 to April 1, 2021. Additional articles were identified using the Evidence-Based Review of Stroke Rehabilitation. STUDY SELECTION Studies were eligible for inclusion if they (1) were RCTs or crossovers published in English, (2) ≥50% of participants were diagnosed and affected by stroke, (3) included adults ≥18 years old, and (4) applied an intervention to the hemiparetic UE as the primary objective of the study. DATA EXTRACTION Two investigators independently screened the title and abstracts, and duplicates were removed. A full-text review was done for studies that met all inclusion criteria. Data were extracted using a custom data extraction template in Covidence and were transferred to online Excel (V16) for data management. Study characteristics and extracted variables were summarized using standard descriptive statistics. Data analyses were performed using SPSS (V29.0). DATA SYNTHESIS A total of 1276 RCTs met inclusion criteria, and of these, 5.2% did not report results on sex, accounting for 5.6% of participants. Women have been underrepresented in stroke RCTs, accounting for 38.8% of participants. Female participation was greater in the acute poststroke phase than in the chronic and subacute phases. Over almost 5 decades, there has been a small decrease in the proportion of female participants in these trials. CONCLUSIONS Evidence-based medicine for the treatment and prevention of stroke is guided by results from RCTs. Generalizability depends on sufficient representation in clinical trials. Stakeholders, such as funders and journal editors, play a key role in encouraging researchers to enroll enough of both sexes and to report the presence or absence of sex differences in RCTs.
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Affiliation(s)
| | - Amber Harnett
- Parkwood Institute Research, Parkwood Institute, London, Canada
| | - Marcus Saikaley
- Parkwood Institute Research, Parkwood Institute, London, Canada
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Janice J Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada; Rehabilitation Research Program, Centre for Aging SMART, Vancouver, Canada
| | - Mark Bayley
- KITE Research Institute, UHN-Toronto Rehabilitation Institute, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Robert Teasell
- Parkwood Institute Research, Parkwood Institute, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
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Dahlby J, Larssen BC, Boyd LA. Examining Sex Differences in Relationships Between Subjective and Objective Measures of Upper Extremity Motor Impairment in a Sample of Stroke Survivors. J Neurol Phys Ther 2024; 48:159-164. [PMID: 38768068 DOI: 10.1097/npt.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND AND PURPOSE Rehabilitation professionals use subjective and objective outcome measures to assess stroke-related impact and impairment. Understanding if subjective and objective findings correlate among stroke survivors, especially if these associations differ between females and males, can inform care decisions. METHODS A retrospective cross-sectional design was used, with data selected from subacute to chronic stroke survivors on age, time since stroke, the hand domain from the Stroke Impact Scale version 3.0 (SIS-H), and the Fugl-Meyer Upper Extremity (FMUE) Assessment. Group differences were assessed for all outcomes based on sex and time poststroke. Separate correlations for females and males were performed between the subjective (SIS-H) and objective measures (FMUE) of upper limb function and impairment. RESULTS Data from 148 participants (44 females) were included in this study. SIS-H was significantly correlated with FMUE in both females and males ( P s ≤ 0.001). No significant differences were found between the groups' mean SIS-H or FMUE scores based on sex or time poststroke. DISCUSSION AND CONCLUSIONS Subjective and objective measures of physical functioning were correlated in both females and males. Although we found no sex differences in our primary outcomes, the sample size of females was disproportionately lower than the males. This is consistent with an ongoing problem in the stroke recovery research field, where females are often underrepresented and understudied, and where females who experience higher levels of impairment are less likely to participate in research.
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Affiliation(s)
- Julia Dahlby
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada (J.D., B.C.L., and L.A.B); and Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada (L.A.B)
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Burton TM, Madsen TE, Karb R, Furie KL. Importance of sex and gender differences in enrollment and interpretation of stroke clinical trials. J Stroke Cerebrovasc Dis 2024; 33:107735. [PMID: 38679215 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/11/2024] [Accepted: 04/25/2024] [Indexed: 05/01/2024] Open
Abstract
OBJECTIVES This review aims to reinforce the importance of improving sex balance in preclinical trials and sex and gender diversity and proportional balance in clinical trials enrollment and how this influences interpretation of stroke clinical trials. It also aims to identify strategies for improvement in data collection. MATERIALS AND METHODS A PubMed search was conducted of publications in English, using MeSH terms sex, sex characteristics, gender identity, transgender, gender-nonconforming persons, clinical trials as topic, stroke. Of 249 search results, 217 were human or animal studies related to stroke, the majority of which were reviews, secondary analyses of stroke clinical trials, meta analyses, or retrospective studies, subject to the methods of sex and gender acquisition per the primary data source. Articles were reviewed, noting inclusion or absence of sex and gender definitions and trial design. Selected articles were supplemented with United States Food and Drug Administration, National Institutes of Health, and National Academy of Science, Engineering, and Medicine publications. RESULTS The majority of preclinical studies continue to report sex as a binary variable, and the majority of stroke clinical trials report sex and gender as interchangeable and binary. Mindful trial design and statistical analysis can improve accuracy in the interpretation of sex and gender differences. Guidance exists to improve reporting on currently accepted sex and gender definitions, recommended data collection instruments, and appropriate statistical analyses. CONCLUSIONS Despite acknowledgement of having failed to achieve diverse and proportionally balanced enrollment, sex and gender imbalance across the research continuum remains prevalent. Responsible incorporation of sex and gender in stroke clinical trials can be achieved through thoughtful study design, use of contemporary sex and gender definitions, inclusive prospective data collection, balanced enrollment with prespecified goals, and appropriate statistical analysis.
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Affiliation(s)
- Tina M Burton
- The Warren Alpert Medical School of Brown University, Department of Neurology, USA.
| | - Tracy E Madsen
- The Warren Alpert Medical School of Brown University, Department of Emergency Medicine, USA; Brown University School of Public Health, USA
| | - Rebecca Karb
- The Warren Alpert Medical School of Brown University, Department of Emergency Medicine, USA
| | - Karen L Furie
- The Warren Alpert Medical School of Brown University, Department of Neurology, USA
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Mehrabi S, Cameron L, Bowman A, Fleet JL, Eng J, Bayley MT, Teasell R. A Systematic Review of Female Participation in Randomized Controlled Trials of Post-Stroke Upper Extremity Rehabilitation in Low- to Middle-Income Countries and High-Income Countries and Regions. Cerebrovasc Dis 2024:1-10. [PMID: 38583429 DOI: 10.1159/000538610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024] Open
Abstract
INTRODUCTION Female participation is lower than males in both acute stroke and stroke rehabilitation trials. However, less is known about how female participation differs across countries and regions. This study aimed to assess the percentage of female participants in randomized controlled trials (RCTs) of post-stroke rehabilitation of upper extremity (UE) motor disorders in low-middle-income (LMICs) and high-income countries (HICs) as well as different high-income world regions. METHODS CINAHL, Embase, PubMed, Scopus, and Web of Science were searched from 1960 to April 1, 2021. Studies were eligible for inclusion if they (1) were RCTs or crossovers published in English; (2) ≥50% of participants were diagnosed with stroke; 3) included adults ≥18 years old; and (4) applied an intervention to the hemiparetic UE as the primary objective of the study. Countries were divided into HICs and LMICs based on their growth national incomes. The HICs were further divided into the three high-income regions of North America, Europe, and Asia and Oceania. Data analysis was performed using SPSS and RStudio v.4.3.1. RESULTS A total of 1,276 RCTs met inclusion criteria. Of them, 298 RCTs were in LMICs and 978 were in HICs. The percentage of female participants was significantly higher in HICs (39.5%) than LMICs (36.9%). Comparing high-income regions, there was a significant difference in the overall female percentages in favor of RCTs in Europe compared to LMICs but not North America or Asia and Oceania. There was no significant change in the percentage of female participants in all countries and regions over the last 2 decades, with no differences in trends between the groups. CONCLUSIONS Sufficient female representation in clinical trials is required for the generalizability of results. Despite differences in overall percentage of female participation between countries and regions, females have been underrepresented in both HICs and LMICs with no considerable change over 2 decades.
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Affiliation(s)
- Sarvenaz Mehrabi
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada,
| | - Lindsay Cameron
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
| | - Andrew Bowman
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care London, London, Ontario, Canada
- Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Janice Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver, British Columbia, Canada
| | - Mark Theodore Bayley
- KITE Research Institute, UHN-Toronto Rehabilitation institute, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Teasell
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care London, London, Ontario, Canada
- Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Matthews S, Cook S, Clayton T, Murray S, Wynne R, Sanders J. Factors affecting women's participation in cardiovascular research: a scoping review. Eur J Cardiovasc Nurs 2024; 23:107-114. [PMID: 37201192 DOI: 10.1093/eurjcn/zvad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
AIMS Women are underrepresented in cardiovascular trials. We sought to explore the proportional representation of women in contemporary cardiovascular research and the factors (barriers and enablers) that affect their participation in cardiovascular studies. METHODS AND RESULTS Multiple electronic databases were searched between January 2011 and September 2021 to identify papers that defined underrepresentation of women in cardiovascular research and/or reported sex-based differences in participating in cardiovascular research and/or barriers for women to participate in cardiovascular research. Data extraction was undertaken independently by two authors using a standardised data collection form. Results were summarised using descriptive statistics and narrative synthesis as appropriate.From 548 identified papers, 10 papers were included. Of those, four were conducted prospectively and six were retrospective studies. Five of the retrospective studies involved secondary analysis of trial data including over 780 trials in over 1.1 million participants. Overall, women were reported to be underrepresented in heart failure, coronary disease, myocardial infarction, and arrhythmia trials, compared to men. Barriers to participation included lack of information and understanding of the research, trial-related procedures, the perceived health status of the participant, and patient-specific factors including travel, childcare availability, and cost. A significantly higher likelihood of research participation was reported by women following a patient educational intervention. CONCLUSION This review has highlighted the underrepresentation of women in a range of cardiovascular trials. Several barriers to women's participation in cardiovascular studies were identified. Researchers could mitigate against these in future trial planning and delivery to increase women's participation in cardiovascular research. REGISTRATION The protocol was published on the public Open Science Framework platform on 13th August 2021 (no registration reference provided) and can be accessed at https://osf.io/ny4fd/.
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Affiliation(s)
- Stacey Matthews
- National Heart Foundation of Australia, 850 Collins Street, Melbourne VIC 3000, Australia
- Royal Melbourne Hospital, 300 Grattan Street, Parkville 3050, Australia
| | - Samantha Cook
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Tim Clayton
- Department of Medical Statistics, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Sarah Murray
- Society of Cardiothoracic Surgery of Great Britain and Ireland, London WC2A 3PE, UK
| | - Rochelle Wynne
- Royal Melbourne Hospital, 300 Grattan Street, Parkville 3050, Australia
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Northfields Ave Wollongong, NSW 2522, Australia
| | - Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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7
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Bushnell C. Stroke in Women: Research Accomplishments and Remaining Gaps. Stroke 2024; 55:467-470. [PMID: 38152958 DOI: 10.1161/strokeaha.123.044176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Cheryl Bushnell
- Department of Neurology, Wake Forest University School of Medicine, Winston Salem, NC
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Field TS, Dizonno V, Almekhlafi MA, Bala F, Alhabli I, Wong H, Norena M, Villaluna MK, King-Azote P, Ratnaweera N, Mancini S, Van Gaal SC, Wilson LK, Graham BR, Sposato LA, Blacquiere D, Dewar BM, Boulos MI, Buck BH, Odier C, Perera KS, Pikula A, Tkach A, Medvedev G, Canfield C, Mortenson WB, Nadeau JO, Alshimemeri S, Benavente OR, Demchuk AM, Dowlatshahi D, Lanthier S, Lee AYY, Mandzia J, Suryanarayan D, Weitz JI, Hill MD. Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis. Stroke 2023; 54:2724-2736. [PMID: 37675613 PMCID: PMC10615774 DOI: 10.1161/strokeaha.123.044113] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Emerging data suggest that direct oral anticoagulants may be a suitable choice for anticoagulation for cerebral venous thrombosis (CVT). However, conducting high-quality trials in CVT is challenging as it is a rare disease with low rates of adverse outcomes such as major bleeding and functional dependence. To facilitate the design of future CVT trials, SECRET (Study of Rivaroxaban for Cerebral Venous Thrombosis) assessed (1) the feasibility of recruitment, (2) the safety of rivaroxaban compared with standard-of-care anticoagulation, and (3) patient-centered functional outcomes. METHODS This was a phase II, prospective, open-label blinded-end point 1:1 randomized trial conducted at 12 Canadian centers. Participants were aged ≥18 years, within 14 days of a new diagnosis of symptomatic CVT, and suitable for oral anticoagulation; they were randomized to receive rivaroxaban 20 mg daily, or standard-of-care anticoagulation (warfarin, target international normalized ratio, 2.0-3.0, or low-molecular-weight heparin) for 180 days, with optional extension up to 365 days. Primary outcomes were annual rate of recruitment (feasibility); and a composite of symptomatic intracranial hemorrhage, major extracranial hemorrhage, or mortality at 180 days (safety). Secondary outcomes included recurrent venous thromboembolism, recanalization, clinically relevant nonmajor bleeding, and functional and patient-reported outcomes (modified Rankin Scale, quality of life, headache, mood, fatigue, and cognition) at days 180 and 365. RESULTS Fifty-five participants were randomized. The rate of recruitment was 21.3 participants/year; 57% of eligible candidates consented. Median age was 48.0 years (interquartile range, 38.5-73.2); 66% were female. There was 1 primary event (symptomatic intracranial hemorrhage), 2 clinically relevant nonmajor bleeding events, and 1 recurrent CVT by day 180, all in the rivaroxaban group. All participants in both arms had at least partial recanalization by day 180. At enrollment, both groups on average reported reduced quality of life, low mood, fatigue, and headache with impaired cognitive performance. All metrics improved markedly by day 180. CONCLUSIONS Recruitment targets were reached, but many eligible participants declined randomization. There were numerically more bleeding events in patients taking rivaroxaban compared with control, but rates of bleeding and recurrent venous thromboembolism were low overall and in keeping with previous studies. Participants had symptoms affecting their well-being at enrollment but improved over time. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03178864.
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Affiliation(s)
- Thalia S Field
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Fouzi Bala
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
- Department of Radiology, Tours University Hospital, France (F.B.)
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Hubert Wong
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Monica Norena
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Maria Karina Villaluna
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Princess King-Azote
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Namali Ratnaweera
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Steven Mancini
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Stephen C Van Gaal
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Laura K Wilson
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, Canada (B.R.G.)
| | - Luciano A Sposato
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Dylan Blacquiere
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Brian M Dewar
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Mark I Boulos
- Sunnybrook Research Institute, Division of Neurology (M.I.B.), University Health Network, University of Toronto, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Canada (B.H.B.)
| | - Celine Odier
- Département de Neurosciences, Centre Hospitalier d'Université de Montréal, Université de Montréal, Canada (C.O.)
| | - Kanjana S Perera
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Canada (K.S.P.)
| | - Aleksandra Pikula
- Krembil Brain Institute (A.P.), University Health Network, University of Toronto, Canada
| | - Aleksander Tkach
- Kelowna General Hospital, Interior Health Authority, Canada (A.T.)
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health Authority, New Westminster, Canada (G.M.)
| | - Carolyn Canfield
- Department of Family Practice, Innovation Support Unit (C.C.), University of British Columbia, Vancouver, Canada
| | - W Ben Mortenson
- Department of Occupational Science and Occupational Therapy (W.B.M.), University of British Columbia, Vancouver, Canada
| | | | | | - Oscar R Benavente
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Dar Dowlatshahi
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Sylvain Lanthier
- Hôpital de Sacre-Coeur de Montréal, Département de Neurosciences, Université de Montréal, Canada (S.L.)
| | - Agnes Y Y Lee
- Division of Hematology (A.Y.Y.L.), University of British Columbia, Vancouver, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Deepa Suryanarayan
- Division of Hematology, Cumming School of Medicine (D.S.), University of British Columbia, Vancouver, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada (J.I.W.)
| | - Michael D Hill
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
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Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes. Can J Cardiol 2022; 38:1865-1880. [PMID: 36116747 DOI: 10.1016/j.cjca.2022.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/21/2022] [Accepted: 09/11/2022] [Indexed: 12/14/2022] Open
Abstract
Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.
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Rodriguez F, Hochman JS, Xu Y, Reynolds HR, Berger JS, Mavromichalis S, Newman JD, Bangalore S, Maron DJ. Screening for participants in the ISCHEMIA trial: Implications for clinical research. J Clin Transl Sci 2022; 6:e90. [PMID: 36003207 PMCID: PMC9389278 DOI: 10.1017/cts.2022.428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/28/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) found that there was no statistical difference in cardiovascular events with an initial invasive strategy as compared with an initial conservative strategy of guideline-directed medical therapy for patients with moderate to severe ischemia on noninvasive testing. In this study, we describe the reasons that potentially eligible patients who were screened for participation in the ISCHEMIA trial did not advance to enrollment, the step prior to randomization. Of those who preliminarily met clinical inclusion criteria on screening logs submitted during the enrollment period, over half did not participate due to physician or patient refusal, a potentially modifiable barrier. This analysis highlights the importance of physician equipoise when advising patients about participation in randomized controlled trials.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | | | - Yifan Xu
- New York University, Grossman School of Medicine, New York, NY, USA
| | | | | | | | | | - Sripal Bangalore
- New York University, Grossman School of Medicine, New York, NY, USA
| | - David J. Maron
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, Stanford University, School of Medicine, Stanford, CA, USA
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11
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Gladstone DJ, Lindsay MP, Douketis J, Smith EE, Dowlatshahi D, Wein T, Bourgoin A, Cox J, Falconer JB, Graham BR, Labrie M, McDonald L, Mandzia J, Ngui D, Pageau P, Rodgerson A, Semchuk W, Tebbutt T, Tuchak C, van Gaal S, Villaluna K, Foley N, Coutts S, Mountain A, Gubitz G, Udell JA, McGuff R, Heran MKS, Lavoie P, Poppe AY. Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020. Can J Neurol Sci 2022; 49:315-337. [PMID: 34140063 DOI: 10.1017/cjn.2021.127] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.
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Affiliation(s)
- David J Gladstone
- Division of Neurology, Department of Medicine, and Regional Stroke Centre, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada
| | | | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Eric E Smith
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences, Calgary, Canada
| | - Dar Dowlatshahi
- University of Ottawa, Department of Neurology, Ottawa, Canada
| | - Theodore Wein
- Stroke Prevention Clinic, McGill University Health Centre, Montreal, Canada
| | - Aline Bourgoin
- Stroke Prevention Clinic, Champlain Regional Stroke Network, Ottawa, Canada
| | - Jafna Cox
- Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - John B Falconer
- Division of Neurology, Faculty of Medicine, University of British Columbia, Kelowna, Canada
| | - Brett R Graham
- Faculty of Medicine, Department of Neurology, University of Saskatchewan, Saskatoon, Canada
| | - Marilyn Labrie
- Faculty of Medicine (Neurology), Laval University, Quebec City, Canada
| | - Lena McDonald
- Heart Health Clinic, St. Martha's Regional Hospital, Antigonish, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, Western University, London, Canada
| | - Daniel Ngui
- Dept of Family Medicine, University of British Columbia, Vancouver, Canada
| | - Paul Pageau
- The Ottawa Hospital, Department of Emergency Medicine, Ottawa, Canada
| | - Amanda Rodgerson
- Provincial Rehabilitation Unit, Queen Elizabeth Hospital, Charlottetown, Canada
| | - William Semchuk
- College of Pharmacy, University of Saskatchewan, Regina, Canada
| | - Tammy Tebbutt
- District Stroke Centre, Waterloo Wellington, Kitchener, Canada
| | - Carmen Tuchak
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Canada
| | - Stephen van Gaal
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | | | - Shelagh Coutts
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences, Calgary, Canada
| | - Anita Mountain
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Jacob A Udell
- Division of Cardiology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Manraj K S Heran
- Division of Neuroradiology, University of British Columbia, Vancouver, Canada
| | - Pascale Lavoie
- Department of Surgery, Laval University; Hôpital de l’Enfant-Jésus, Quebec City, Canada
| | - Alexandre Y Poppe
- Department of Neurosciences, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
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12
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Rissanen R. A snapshot of an eCohort: A comparison of the LifeGene population at baseline with the Swedish general population. Scand J Public Health 2022; 50:930-934. [PMID: 35365049 DOI: 10.1177/14034948211047776] [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: 11/16/2022]
Abstract
AIMS With access to technologies and internet around the globe, opportunities have been provided to contact and recruit participants at a more rapid pace, without face-to-face contact. However, 'eCohorts' may yield substantial volunteer bias. Few studies have compared eCohorts to general populations or samples where traditional research methods have been applied. To our knowledge, no prior analyses have reported on Swedish-based LifeGene eCohort, in comparison with the Swedish general population. The aim of this study was to compare the LifeGene eCohort at baseline with the Swedish general population. METHODS The LifeGene eCohort (n = 39,862) was compared with the general population in Sweden represented by weighted data from the Swedish Public Health agency and Statistics Sweden. LifeGene is a nationwide project with yearly data collection. Descriptive statistics were used to compare demographic characteristics, and self-reported data on diagnosis of depression. RESULTS The LifeGene eCohort overrepresented younger people, females, those with a higher socio-economic status, non-smokers and people with a diagnosis of depression. Surprisingly, the eCohort included a larger percentage of people born outside of Sweden compared to the general population, which is not in line with previous studies. CONCLUSION The results show that the participants in the LifeGene eCohort are different regarding demographic variables and some health indicators from the Swedish general population. Hence, if comparisons are made between the LifeGene eCohort and a general population it becomes important to be aware of the differences that might exist between the different cohort populations and how these might affect the estimates.
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Affiliation(s)
- Ritva Rissanen
- Department of Global Public Health, Karolinska Institutet, Sweden
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13
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Kim J, Kim MG, Lim KM. Participation in and withdrawal from cancer clinical trials: A survey of clinical research coordinators. Asia Pac J Oncol Nurs 2022; 9:197-201. [PMID: 35571627 PMCID: PMC9096735 DOI: 10.1016/j.apjon.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Poor accrual and withdrawal are the main reasons for the failure of cancer clinical trials. As clinical research coordinators (CRCs) work at the frontlines of clinical trials, CRCs can best identify the main factors that influence patient participation and dropout and suggest potential remedial measures. This study aimed to investigate participation and withdrawal in cancer clinical trials through a survey of CRCs. Furthermore, we collected suggestions of CRCs to increase patient participation and reduce withdrawal from cancer clinical trials. Methods This cross-sectional survey among 100 CRC nurses currently coordinating cancer clinical trials and having more than six months of experience was conducted at four hospitals in South Korea between March and August 2021. We designed a questionnaire based on prior studies, and the key items included characteristics of respondents, characteristics of clinical trials, clinical trial participation, and withdrawal. Results Patients refused to participate due to concern about adverse events (46.5%) and negative perception of clinical trials (44.4%). The main reasons for study withdrawal were disease progression (71.5%), adverse events (10.6%), and withdrawal of consent due to personal issues (5.5%). The provision of sufficient explanation was suggested as a remedial measure for increasing consent to participate (67.4%) and reducing withdrawal (21.8%). Conclusions A survey of CRCs revealed the reasons governing patient participation and withdrawal in cancer clinical trials, thereby providing a novel insight into strategies for promoting subject enrollment and reducing withdrawal from cancer clinical trials.
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14
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Jiménez-Sánchez L, Hamilton OKL, Clancy U, Backhouse EV, Stewart CR, Stringer MS, Doubal FN, Wardlaw JM. Sex Differences in Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:756887. [PMID: 34777227 PMCID: PMC8581736 DOI: 10.3389/fneur.2021.756887] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/04/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Cerebral small vessel disease (SVD) is a common cause of stroke, mild cognitive impairment, dementia and physical impairments. Differences in SVD incidence or severity between males and females are unknown. We assessed sex differences in SVD by assessing the male-to-female ratio (M:F) of recruited participants and incidence of SVD, risk factor presence, distribution, and severity of SVD features. Methods: We assessed four recent systematic reviews on SVD and performed a supplementary search of MEDLINE to identify studies reporting M:F ratio in covert, stroke, or cognitive SVD presentations (registered protocol: CRD42020193995). We meta-analyzed differences in sex ratios across time, countries, SVD severity and presentations, age and risk factors for SVD. Results: Amongst 123 relevant studies (n = 36,910 participants) including 53 community-based, 67 hospital-based and three mixed studies published between 1989 and 2020, more males were recruited in hospital-based than in community-based studies [M:F = 1.16 (0.70) vs. M:F = 0.79 (0.35), respectively; p < 0.001]. More males had moderate to severe SVD [M:F = 1.08 (0.81) vs. M:F = 0.82 (0.47) in healthy to mild SVD; p < 0.001], and stroke presentations where M:F was 1.67 (0.53). M:F did not differ for recent (2015-2020) vs. pre-2015 publications, by geographical region, or age. There were insufficient sex-stratified data to explore M:F and risk factors for SVD. Conclusions: Our results highlight differences in male-to-female ratios in SVD severity and amongst those presenting with stroke that have important clinical and translational implications. Future SVD research should report participant demographics, risk factors and outcomes separately for males and females. Systematic Review Registration: [PROSPERO], identifier [CRD42020193995].
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Affiliation(s)
- Lorena Jiménez-Sánchez
- Translational Neuroscience PhD Programme, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Olivia K. L. Hamilton
- Translational Neuroscience PhD Programme, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
| | - Una Clancy
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Ellen V. Backhouse
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Catriona R. Stewart
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael S. Stringer
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Fergus N. Doubal
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna M. Wardlaw
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Lothian Birth Cohorts, University of Edinburgh, Edinburgh, United Kingdom
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15
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Weerasekara I, Baye J, Burke M, Crowfoot G, Mason G, Peak R, Simpson D, Walker FR, Nilsson M, Pollack M, English C. What do stroke survivors' value about participating in research and what are the most important research problems related to stroke or transient ischemic attack (TIA)? A survey. BMC Med Res Methodol 2021; 21:209. [PMID: 34629050 PMCID: PMC8502417 DOI: 10.1186/s12874-021-01390-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Recruitment to stroke clinical trials is challenging, but consumer registers can facilitate participation. Researchers need to understand the key factors that facilitate trial involvement and improve consumer partnerships to identify what research topics important to stroke and transient ischemic attack (TIA) survivors and their carers. We aimed to examine i) the experience of being involved in a stroke research register, and ii) the priorities for stroke research from the perspective of stroke survivors. Methods Online and paper-based surveys were sent directly to members of a stroke register and disseminated online. Multiple choice questions were reported as counts and percentages and open-ended questions were thematically analysed using Braun and Clarke’s 6-stage process. Results Of 445 survey respondents, 154 (38%) were a member of the Stroke Research Register. The most frequently reported reason for research participation was to help others in the future. Respondents reported they were less likely to take part in research if the research question was not relevant to them, if transport was an issue, or because they lacked time. The most important research problems reported were targeting specific impairments including recovery of movement, fatigue, and aphasia, improvement of mental health services, and increased support for carers. Conclusions Recruitment to trials may be improved by research registers if an inclusive research culture is fostered, in which consumers feel valued as members of a community, have direct and timely access to research findings and the opportunity to be meaningfully involved in research around the problems that consumers find most important. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01390-y.
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Affiliation(s)
- Ishanka Weerasekara
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia. .,Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka. .,Hunter Medical Research Institute, New Lambton Heights, Australia.
| | - Jasmine Baye
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia
| | | | - Gary Crowfoot
- School of Nursing and Midwifery and Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia
| | - Gillian Mason
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia.,Centre for Rehab Innovations, School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Rachael Peak
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia
| | - Dawn Simpson
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia
| | - Frederick Rohan Walker
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia
| | - Michael Nilsson
- Hunter Medical Research Institute, New Lambton Heights, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia.,Centre for Rehab Innovations, School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Michael Pollack
- Rehabilitation Medicine, John Hunter Hospital, New Lambton Heights, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
| | - Coralie English
- School of Health Sciences, College of Health, Medicine and Wellbeing & Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Centre for Research Excellence in Stroke Recovery and Rehabilitation, Florey Institute of Neuroscience and Hunter Medical Research Institute, Parkville, Australia
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16
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van Diemen J, Verdonk P, Chieffo A, Regar E, Mauri F, Kunadian V, Sharma G, Mehran R, Appelman Y. The importance of achieving sex- and gender-based equity in clinical trials: a call to action. Eur Heart J 2021; 42:2990-2994. [PMID: 34352884 PMCID: PMC8370758 DOI: 10.1093/eurheartj/ehab457] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/14/2020] [Accepted: 07/06/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jeske van Diemen
- Department of Internal Medicine, Amsterdam UMC, VU
University, De Boelelaan 1118 (4A-45), 1081 HZ Amsterdam, the Netherlands
| | - Petra Verdonk
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU
University, De Boelelaan 1118, 1081 HZ Amsterdam, the Netherlands
| | - Alaide Chieffo
- Interventional cardiology unit, San Raffaele scientific institute, Via
olgettina 60, 20132 Milan, Italy
| | - Evelyn Regar
- Clinical Study Center, University Hospital, LMU Munich, Campus Innenstadt,
Lindwurmstr. 2a, 80336 Munich, Germany
| | - Fina Mauri
- Department of Cardiology, Hospital Universitari Germans Trias i
Pujol, Carretera de Canyet, 08916 Badalona, Barcelona, Spain
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences,
Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne
NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, UK
| | - Garima Sharma
- Division of Cardiology, Johns Hopkins Ciccarone Center for the Prevention
of Cardiovascular Disease, Johns Hopkins University School of Medicine,
733 N Broadway, Baltimore, MD 21205, Maryland, USA
| | - Roxana Mehran
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular
Institute, Icahn School of Medicine at Mount Sinai, Gustave L. Levy Pl,
New York, NY 10029, USA
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, De
Boelelaan 1118, 1081 HZ Amsterdam, the Netherlands
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17
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Strong B, Pudar J, Thrift AG, Howard VJ, Hussain M, Carcel C, de Los Campos G, Reeves MJ. Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis. JAMA Neurol 2021; 78:666-677. [PMID: 33900363 DOI: 10.1001/jamaneurol.2021.0873] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments. Objective To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations. Data Sources MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020. Study Selection Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset. Data Extraction Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database. Main Outcomes and Measures The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates. Results The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women. Conclusions and Relevance Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.
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Affiliation(s)
- Brent Strong
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Julia Pudar
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Murtaza Hussain
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Cheryl Carcel
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gustavo de Los Campos
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
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18
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Carcel C, Reeves M. Under-Enrollment of Women in Stroke Clinical Trials: What Are the Causes and What Should Be Done About It? Stroke 2021; 52:452-457. [PMID: 33493049 DOI: 10.1161/strokeaha.120.033227] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The under-representation of women in clinical trials is a commonly recognized and seemingly intractable problem in many different areas of clinical medicine. Discrepancies in the enrollment of women in clinical trials raises concerns about the generalizability of trial evidence, as well as the potential for reduced access and utilization of new therapies in women. Recent studies confirm that the problem of under-enrollment of women continues to exist in stroke clinical trials, even after accounting for the sex ratio of stroke cases in the underlying population. The origins of these disparities are complex, and there remains a relative dearth of stroke studies that have examined the causes in detail. Although caution should be used when generalizing research findings from studies conducted in other medical conditions including cardiology trials, factors that contribute to lower enrollment in women include the use of specific trial eligibility criteria (eg, older age, presence of specific comorbidities), patient attitudes and beliefs (resulting in less interest and more refusals in women), and potentially implicit biases among study personnel. Beyond a general call to prioritize stroke research in this area, we also recommend the greater use of trial screening logs, the use of qualitative studies to understand patient attitudes and beliefs towards stroke research, avoiding the use of age-based exclusion criteria (eg, >80 years), and increasing the number of women who lead stroke clinical trials.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (C.C.).,The University of Sydney, Sydney School of Public Health, Sydney Medical School, New South Wales, Australia (C.C.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing (M.R.)
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19
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Hall KT, Vase L, Tobias DK, Dashti HT, Vollert J, Kaptchuk TJ, Cook NR. Historical Controls in Randomized Clinical Trials: Opportunities and Challenges. Clin Pharmacol Ther 2020; 109:343-351. [PMID: 32602555 DOI: 10.1002/cpt.1970] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
Randomized control trials (RCTs) with placebo are the gold standard for determining efficacy of novel pharmaceutical treatments. Since their inception, over 75 years ago, researchers have amassed a large body of underutilized data on outcomes in the placebo control arms of these trials. Although rare disease indications have used these historical placebo data as synthetic controls to reduce burden on patients and accelerate drug discovery, broad use of historical controls is in its infancy. Large-scale historical placebo data could be leveraged to benefit both drug developers and patients if warehoused and made more available to guide trial design and analysis. Here, we examine challenges in utilizing historical controls related to heterogeneity in trial design, outcome ascertainment, patient characteristics, and unmeasured pharmacogenomic effects. We then discuss the advantages and disadvantages of current approaches and propose a path forward to broader use of historical controls in RCTs.
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Affiliation(s)
- Kathryn T Hall
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lene Vase
- Department of Psychology and Behavioral Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Deirdre K Tobias
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hesam T Dashti
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Neurophysiology, Centre for Biomedicine and Medical Technology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University, Heidelberg, Germany
| | - Ted J Kaptchuk
- Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nancy R Cook
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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20
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Hawe RL, Cluff T, Dowlatshahi D, Hill MD, Dukelow SP. Assessment of Sex Differences in Recovery of Motor and Sensory Impairments Poststroke. Neurorehabil Neural Repair 2020; 34:746-757. [PMID: 32672513 DOI: 10.1177/1545968320935811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Understanding potential sex differences in stroke recovery is important for prognosis, ensuring appropriate allocation of health care resources, and for stratification in research studies. Previously, functional measures have shown poorer outcomes for females, however, little is known about sex differences that may exist in specific motor and sensory impairments. Objective. The aim of this study was to utilize robotic assessments of motor and sensory impairments to determine if there are sex differences at the impairment level in stroke recovery over the first 6 months poststroke. Methods. We used robotic and clinical assessments of motor and sensory impairments at 1, 6, 12, and 26 weeks poststroke in 108 males and 52 females. Linear mixed models were used to examine the effect of sex on recovery poststroke, controlling for age and lesion volume. Results. In general, we did not find significant sex differences across a range of assessments. The exception to this was a sex × age interaction for the Purdue Pegboard Assessment, where we found that females had better performance than males at younger ages (<62 years), but males had better performance at older ages. Conclusions. While recruitment biases need to be acknowledged when generalizing our results to stroke recovery at-large, our results suggest that sex differences do not exist at the impairment level poststroke.
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Affiliation(s)
- Rachel L Hawe
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Tyler Cluff
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sean P Dukelow
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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21
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Porter AL, Ebot J, Lane K, Mooney LH, Lannen AM, Richie EM, Dlugash R, Mayo S, Brott TG, Ziai W, Freeman WD, Hanley DF. Enhancing the Informed Consent Process Using Shared Decision Making and Consent Refusal Data from the CLEAR III Trial. Neurocrit Care 2020; 32:340-347. [PMID: 31571176 DOI: 10.1007/s12028-019-00860-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The process of informed consent in National Institutes of Health randomized, placebo-controlled trials is poorly studied. There are several issues regarding informed consent in emergency neurologic trials, including a shared decision-making process with the patient or a legally authorized representative about overall risks, benefits, and alternative treatments. METHODS To evaluate the informed consent process, we collected best and worst informed consent practice information from a National Institutes of Health trial and used this in medical simulation videos to educate investigators at multiple sites to improve the consent process. Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) (clinicaltrials.gov, NCT00784134) studied the effect of intraventricular alteplase (n = 251) versus saline (placebo) injections (n = 249) for intraventricular hemorrhage reduction. Reasons for ineligibility (including refusing to consent) for all screen failures were analyzed. The broadcasted presentation outlined best practices for doctor-patient interactions during the consenting process, as well as anecdotal, study-specific reasons for consent refusal. Best and worst consent elements were then incorporated into a simulation video to enhance the informed consent process. This video was disseminated to trial sites as a webinar around the midpoint of the trial to improve the consent process. Pre- and post-intervention consent refusals were compared. RESULTS During the trial, 10,538 patients were screened for eligibility, of which only three were excluded due to trial timing. Pre-intervention, 77 of 5686 (1.40%) screen eligible patients or their proxies refused consent. Post-intervention, 55 of 4849 (1.10%) refused consent, which was not significantly different from pre-intervention (P = 0.312). The incidence of screen failures was significantly lower post-intervention (P = 0.006), possibly due to several factors for patient exclusion. CONCLUSION The informed consent process for prospective randomized trials may be enhanced by studying and refining best practices based on trial-specific plans and patient concerns particular to a study.
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Affiliation(s)
- Amanda L Porter
- Department of Neurology, Mayo Clinic Alix School of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - James Ebot
- Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Karen Lane
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
| | - Lesia H Mooney
- Department of Nursing, Mayo Clinic, Jacksonville, FL, USA
| | - Amy M Lannen
- J. Wayne and Delores Barr Weaver Simulation Center, Mayo Clinic, Jacksonville, FL, USA
| | - Eugene M Richie
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Rachel Dlugash
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
| | - Steve Mayo
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Wendy Ziai
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Daniel F Hanley
- Brain Injury Outcomes (BIOS) Division, Johns Hopkins University, Baltimore, MD, USA
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22
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Musiałek P, Roubin GS. Commentary: Double-Layer Carotid Stents: From the Clinical Need, through a Stent-in-Stent Strategy, to Effective Plaque Isolation… the Journey Toward Safe Carotid Revascularization Using the Endovascular Route. J Endovasc Ther 2019; 26:572-577. [DOI: 10.1177/1526602819861546] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Piotr Musiałek
- Jagiellonian University Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary S. Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL, USA
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