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Raymond J, Boisseau W, Nguyen TN, Darsaut TE. How science can harm: The true history of thrombectomy trials. Neurochirurgie 2024; 70:101588. [PMID: 39255677 DOI: 10.1016/j.neuchi.2024.101588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 09/03/2024] [Indexed: 09/12/2024]
Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - William Boisseau
- Service of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Thanh N Nguyen
- Department of Neurology and Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Tim E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Boisseau W, Nguyen TN, Darsaut TE. Understanding why restrictive trial eligibility criteria are inappropriate. Neurochirurgie 2024; 70:101589. [PMID: 39244816 DOI: 10.1016/j.neuchi.2024.101589] [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: 08/07/2024] [Accepted: 09/03/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND An important difference between explanatory and pragmatic clinical trials concerns eligibility criteria. Eligibility criteria are restrictive in explanatory trials, while pragmatic trials are more inclusive or even all-inclusive. METHODS To better understand the diverging views regarding eligibility criteria, we examine the contrast between theoretical and clinical medicine, and 3 different research contexts: laboratory research, population studies and clinical trials. In each context we review the purpose for selecting study subjects or research material, as well as the type of inductive inference or generalization that is sought by such selection. RESULTS In each context, selection concerns different things and serves different purposes: In the laboratory, selection concerns the homogenous research material that will help isolate a causal signal. In the epidemiological context selection concerns the (random) sampling method, designed to produce a representative sample of the population. In the clinical trial setting, selection concerns patients in need of care. Restrictive eligibility criteria become inappropriate in the care setting because the aim of the trial is not to represent a population nor to isolate a causal signal, but to find out which patients benefit from treatment. CONCLUSION The idea of selecting patients comes from methods that belong to theoretical medicine. In the care setting, most clinical trials should be pragmatic and as inclusive as possible.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - William Boisseau
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Service of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Thanh N Nguyen
- Department of Neurology and Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Tim E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Fahed R, Darsaut TE. Ethical Problems of Observational Studies and Big Data Compared to Randomized Trials. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024; 49:389-398. [PMID: 38739037 DOI: 10.1093/jmp/jhae021] [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] [Indexed: 05/14/2024] Open
Abstract
The temptation to use prospective observational studies (POS) instead of conducting difficult trials (RCTs) has always existed, but with the advent of powerful computers and large databases, it can become almost irresistible. We examine the potential consequences, were this to occur, by comparing two hypothetical studies of a new treatment: one RCT, and one POS. The POS inevitably submits more patients to inferior research methodology. In RCTs, patients are clearly informed of the research context, and 1:1 randomized allocation between experimental and validated treatment balances risks for each patient. In POS, for each patient, the risks of receiving inferior treatment are impossible to estimate. The research context and the uncertainty are down-played, and patients and clinicians are at risk of becoming passive research subjects in studies performed from an outsider's view, which potentially has extraneous objectives, and is conducted without their explicit, autonomous, and voluntary involvement and consent.
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Affiliation(s)
- Jean Raymond
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Robert Fahed
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
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Boisseau W, Darsaut TE, Raymond J. In Reply to the Letter to the Editor Regarding: "Endovascular Parent Vessel Occlusion Versus Flow Diversion in the Treatment of Large and Giant Aneurysms: A Randomized Comparison". World Neurosurg 2024; 187:275-276. [PMID: 38970195 DOI: 10.1016/j.wneu.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 07/08/2024]
Affiliation(s)
- William Boisseau
- Department of Interventional Neuroradiology, Fondation Adolphe de Rothschild, Paris, France
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jean Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Raymond J, Darsaut TE. Surgical randomized trials: how to prevent the comic opera from becoming a tragedy. Neurochirurgie 2024; 70:101568. [PMID: 38749317 DOI: 10.1016/j.neuchi.2024.101568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - Tim E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Boisseau W, Darsaut TE, Fahed R, Comby PO, Drake B, Lesiuk H, Rempel JL, O'Kelly CJ, Chow MMC, Iancu DE, Roy D, Weill A, Klink R, Raymond J. Endovascular Parent Vessel Occlusion Versus Flow Diversion in the Treatment of Large and Giant Aneurysms: A Randomized Comparison. World Neurosurg 2024; 185:e700-e712. [PMID: 38417622 DOI: 10.1016/j.wneu.2024.02.114] [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: 01/15/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Parent vessel occlusion (PVO) is a time-honored treatment for unclippable or uncoilable intracranial aneurysms. Flow diversion (FD) is a recent endovascular alternative that can occlude the aneurysm and spare the parent blood vessel. Our aim was to compare outcomes of FD with endovascular PVO. METHODS This is a prespecified treatment subgroup analysis of the Flow diversion in Intracranial Aneurysms trial (FIAT). FIAT was an investigator-led parallel-group all-inclusive pragmatic randomized trial. For each patient, clinicians had to prespecify an alternative management option to FD before stratified randomization. We report all patients for whom PVO was selected as the best alternative treatment to FD. The primary outcome was a composite of core-lab determined angiographic occlusion or near-occlusion at 3-12 months combined with an independent clinical outcome (mRS<3). Primary analyses were intent-to-treat. There was no blinding. RESULTS There were 45 patients (16.2% of the 278 FIAT patients randomized between 2011 and 2020 in 3 centers): 22 were randomly allocated to FD and 23 to PVO. Aneurysms were mainly large or giant (mean 22 mm) anterior circulation (mainly carotid) aneurysms. A poor primary outcome was reached in 11/22 FD (50.0%) compared to 9/23 PVO patients (39.1%) (RR: 1.28, 95% CI [0.66-2.47]; P = 0.466). Morbidity (mRS >2) at 1 year occurred in 4/22 FD and 6/23 PVO patients. Angiographic results and serious adverse events were similar. CONCLUSIONS The comparison between PVO and FD was inconclusive. More randomized trials are needed to better determine the role of FD in large aneurysms eligible for PVO.
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Affiliation(s)
- William Boisseau
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Department of Interventional Neuroradiology, Fondation Adolphe de Rothschild, Paris, France
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Robert Fahed
- Departments of Neurology, Neuroradiology, Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Pierre Olivier Comby
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Department of Neuroradiology and Emergency Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Brian Drake
- Departments of Neurology, Neuroradiology, Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Howard Lesiuk
- Departments of Neurology, Neuroradiology, Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cian J O'Kelly
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Michael M C Chow
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Daniela E Iancu
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Ruby Klink
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Saragih ID, Suarilah I, Hsiao CT, Fann WC, Lee BO. Interdisciplinary simulation-based teaching and learning for healthcare professionals: A systematic review and meta-analysis of randomized controlled trials. Nurse Educ Pract 2024; 76:103920. [PMID: 38382335 DOI: 10.1016/j.nepr.2024.103920] [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: 11/08/2023] [Revised: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
AIM This study aimed to investigate the effects of interdisciplinary simulation-based teaching and learning on the interprofessional knowledge of healthcare professionals. BACKGROUND Interdisciplinary simulation-based teaching and learning have been employed to prepare learners to collaborate in clinical settings. This strategy could help healthcare professionals to better understand each other, develop interdisciplinary shared values and promote mutual respect between professions, while reducing errors and adverse events in hospital. A meta-analysis was performed to investigate the effects of interdisciplinary simulation-based teaching and learning on healthcare professionals. DESIGN A systematic review and meta-analysis. METHODS A systematic search was conducted of databases including Academic Search Complete, CINAHL Plus with full text, Cochrane Library, Embase, Medline Complete, PubMed and Web of Science from their inception to September 5, 2023. The study included randomized controlled trials that provided interdisciplinary simulation-based education to healthcare professionals. Protocol trials or studies that did not include median or mean and standard deviation were excluded. The pooled standardized mean differences of outcomes were analyzed using a DerSimonian-Laird random-effects model. Heterogeneity was assessed using I2. Egger's regression test was used to examine publication bias indicated in forest plots. RESULTS Ten randomized control trials with a total of 766 participants were included in the pooled analyses. Interdisciplinary simulation-based teaching and learning positively enhanced the interprofessional knowledge of healthcare professionals (pooled SMD = 0.30; 95% CI = 0.10-0.50; p < 0.001). Egger's regression test results were non-significant, indicating that publication bias had little impact on the pooled SMDs. CONCLUSION Interdisciplinary simulation-based teaching and learning for health professionals appear to be significantly beneficial for increasing their interprofessional knowledge. This strategy highlights the importance of providing a well-developed scenario with relevant properties, which applies valid and rigorous instruments, to measure behavioral changes induced by interdisciplinary simulation-based teaching and learning.
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Affiliation(s)
| | - Ira Suarilah
- Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan, ROC; School of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan, ROC
| | - Bih-O Lee
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Center for Innovative Research on Aging Society (CIRAS), National Chung Cheng University, Taiwan, ROC.
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Daly T. Improving Clinical Trials of Antioxidants in Alzheimer's Disease. J Alzheimers Dis 2024; 99:S171-S181. [PMID: 37781800 DOI: 10.3233/jad-230308] [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] [Indexed: 10/03/2023]
Abstract
Maintaining diversity in drug development in research into Alzheimer's disease (AD) is necessary to avoid over-reliance on targeting AD neuropathology. Treatments that reduce or prevent the generation of oxidative stress, frequently cited for its causal role in the aging process and AD, could be useful in at-risk populations or diagnosed AD patients. However, in this review, it is argued that clinical research into antioxidants in AD could provide more useful feedback as to the therapeutic value of the oxidative stress theory of AD. Improving comparability between randomized controlled trials (RCTs) is vital from a waste-reduction and priority-setting point of view for AD clinical research. For as well as attempting to improve meaningful outcomes for patients, RCTs of antioxidants in AD should strive to maximize the extraction of clinically useful information and actionable feedback from trial outcomes. Solutions to maximize information flow from RCTs of antioxidants in AD are offered here in the form of checklist questions to improve ongoing and future trials centered around the following dimensions: adhesion to reporting guidelines like CONSORT, biomarker enrichment, simple tests of treatment, and innovative trial design.
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Affiliation(s)
- Timothy Daly
- Science Norms Democracy UMR 8011, Sorbonne Université, Paris, France
- Bioethics Program, FLACSO Argentina, Buenos Aires, Argentina
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Raymond J, Valvassori L, Darsaut TE. Understanding the role of randomization in clinical research and practice. Neurochirurgie 2023; 69:101492. [PMID: 37742489 DOI: 10.1016/j.neuchi.2023.101492] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The scientific role randomization plays in clinical research is universally recognized, but poorly understood. In stark contrast, the ethical role randomization plays in the proper care of patients in the presence of uncertainty has been almost completely ignored. METHODS We review the introduction of randomization in the design of experiments, its first use in Britain, and its essential role in analysis of statistical results. We also review Thomas Chalmers' argument from 1975 that showed the ethical role randomization can play in the care of patients. We discuss how Chalmers' vision can be generalized to all contexts of clinical uncertainty. DISCUSSION Randomization is not only essential to the validity of statistical tests, it is also the best way to learn from experience. Although Chalmers' admonition to 'Randomize the first patient' pertained to the use of innovations, the notion that randomized allocation can be done in the best interest of patients is generalizable to all medical or surgical interventions that have yet to be proven beneficial, opening the perspective that care research can be integrated into practice in the best medical interest of patients. CONCLUSION Randomized allocation plays crucial scientific and ethical roles both in research and practice. It is the most efficient way to learn from experience. Prior to this gain in knowledge, it is the way to optimize care in the presence of uncertainty.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | | | - Tim E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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10
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Raymond J, Darsaut TE. Understanding categories or subgroups and a common clinical reasoning error: the example of aneurysm size and neck width. Neurochirurgie 2023; 69:101491. [PMID: 37734248 DOI: 10.1016/j.neuchi.2023.101491] [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: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Individualized clinical decisions are often made by considering some patient or lesion characteristics that are thought to have an impact on the efficacy or safety of treatment. For example, aneurysm size and neck width have often been determinants of treatment choices in neurovascular practice. METHODS We review observational and randomized data on the influence of aneurysm or neck size on angiographic results of coiling, stent-assisted coiling, or surgical clipping. New RCT data are used to demonstrate the shortcomings of managing patients using clinical judgment regarding patient or lesion characteristics. We discuss why clinical decisions should not be based on comparisons of different patients treated by the same treatment. Clinical decision making requires a comparison between the same patients treated with different treatments in a randomized trial. RESULTS The results of endovascular treatment of large or wide-necked aneurysms are always inferior to those of small or narrow-necked aneurysms, in observational as well as in randomized studies. However, this fact alone is not sufficient to infer that patients with small aneurysms should be coiled, while those with large aneurysms should be managed with stenting or surgical clipping. The purported superiority of clipping for large aneurysms could not be demonstrated in recent RCTs (while surgery was found superior for small aneurysms). Similarly, the superiority of stent-assisted coiling for wide-necked aneurysms was not shown in another recent RCT. CONCLUSION Clinical experience and observational studies alone can mislead practice. Proper clinical decisions for individuals requires randomized evidence.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, Alberta, Canada
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Chan VKY, Darsaut TE, Bailey CS, Raymond J. Understanding crossovers and potential ways to mitigate the problem: Lessons from influential trials on lumbar microdiscectomy. Neurochirurgie 2023; 69:101461. [PMID: 37450957 DOI: 10.1016/j.neuchi.2023.101461] [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: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Lumbar microdiscectomy is the most frequent surgical intervention used in the treatment of sciatica from herniated lumbar discs. Many discectomy trials have been plagued with an excessive number of crossovers that have rendered results inconclusive. METHODS We review the design and results of influential lumbar microdiscectomy trials. We also discuss the various strategies that have been used to decrease the number of crossovers or to mitigate the effects of crossovers on analyses. RESULTS Randomized trials on lumbar discectomy were affected by crossover rates of 8% to 42%. Various strategies that have been used to decrease that number or to mitigate the effects on results include: patient selection, blinding (placebo-controlled trials), an immediate access to surgery for the surgical group (but limited access to surgery for the conservative group), shortening the follow-up period necessary to reach the primary outcome measure, postponing crossovers to surgery after determination of the primary outcome, and modifying the primary outcome measure to include treatment failures. Crossovers should be anticipated and compensated for by increasing the number of participants. CONCLUSION Non-adherence to randomly allocated management options can deprive trials of the statistical power needed to inform clinical care. Crossovers and ways to mitigate related problems should be anticipated at the time of trial design.
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Affiliation(s)
- V K Y Chan
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112, Street NW, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112, Street NW, Edmonton, Alberta, Canada
| | - C S Bailey
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - J Raymond
- Department of Radiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Raymond J, Darsaut TE. Reply. AJNR Am J Neuroradiol 2023; 44:E36-E37. [PMID: 37500283 PMCID: PMC10411846 DOI: 10.3174/ajnr.a7958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
- J Raymond
- Department of RadiologyCentre Hospitalier de l'Université de MontréalMontreal, Québec, Canada
| | - T E Darsaut
- University of Alberta HospitalEdmonton, Alberta, Canada
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Raymond J, Chan VKY, Darsaut TE. Understanding how the research question impacts trial design: Examples from discectomy trials. Neurochirurgie 2023; 69:101460. [PMID: 37413815 DOI: 10.1016/j.neuchi.2023.101460] [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: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Formulating a pertinent research question is of the utmost importance in clinical research. An ill-conceived question may lead to an erroneous trial design, which may adversely affect the care of patients and provide uninformative or even misleading results. METHODS We review the research question of a randomized trial on the timing of lumbar discectomy. We compare the resulting design with other trials, real or hypothetical, that would have been more appropriate. RESULTS The RCT we examine randomly allocated patients to early or delayed surgery to answer a theoretical question of the effect of time on the efficacy of surgery. The trial was interpreted to have shown that early surgery was associated with better clinical and functional outcomes as compared to delayed surgery. This conclusion is clinically misleading. Valid comparisons between groups should be performed on intent-to-treat analyses and at the same time points after randomization (and not at a fixed follow-up period after surgery). The clinically pertinent comparison is not between the theoretical efficacy of surgery performed at various times, but between surgery and conservative management in patients presenting at various times. Better-designed trials on the clinical benefits of lumbar discectomy, including the treatment of chronic sciatica, have been published. CONCLUSION Theoretical research questions inspired from observational data can lead to erroneous trial design. Prospective randomized trials impact practice immediately: they are unique occasions to address clinical problems and optimize care under uncertainty in real time. However, they require the research question to be formulated with great care.
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Affiliation(s)
- J Raymond
- Division of Neurosurgery, Department of Radiology, service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
| | - V K Y Chan
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Darsaut TE, Raymond J. 'It is not the answer which enlightens, but the question'. Neurochirurgie 2023; 69:101446. [PMID: 37178487 DOI: 10.1016/j.neuchi.2023.101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112 St NW, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, centre hospitalier de l'université de Montréal (CHUM), room D03.5462b, Montreal, H2X 0C1 Quebec, Canada.
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Raymond J, Gentric JC, Magro E, Nico L, Bacchus E, Klink R, Cognard C, Januel AC, Sabatier JF, Iancu D, Weill A, Roy D, Bojanowski MW, Chaalala C, Barreau X, Jecko V, Papagiannaki C, Derrey S, Shotar E, Cornu P, Eker OF, Pelissou-Guyotat I, Piotin M, Aldea S, Beaujeux R, Proust F, Anxionnat R, Costalat V, Corre ML, Gauvrit JY, Morandi X, Brunel H, Roche PH, Graillon T, Chabert E, Herbreteau D, Desal H, Trystram D, Barbier C, Gaberel T, Nguyen TN, Viard G, Gevry G, Darsaut TE. Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2023; 138:1393-1402. [PMID: 37132535 DOI: 10.3171/2022.9.jns22987] [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: 05/05/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries. METHODS Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%-22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%-28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%-25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%-21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%-37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%-20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%-40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%-21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%-35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%-29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%-33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%-34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%-26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%-34%). CONCLUSIONS Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.
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Affiliation(s)
- Jean Raymond
- 1Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | | | - Elsa Magro
- 3Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Lorena Nico
- 4Department of Radiology, CHU Saint-Etienne, France
| | - Emma Bacchus
- 5Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- 1Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | | | | | - Jean-François Sabatier
- 7Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Daniela Iancu
- 1Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Alain Weill
- 1Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Daniel Roy
- 1Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Michel W Bojanowski
- 8Department of Surgery, Division of Neurosurgery, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Chiraz Chaalala
- 8Department of Surgery, Division of Neurosurgery, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Xavier Barreau
- 9Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, France
| | - Vincent Jecko
- 10Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, France
| | | | - Stéphane Derrey
- 12Neurosurgery, Charles Nicolle Hospital, Rouen Normandy University Hospital, Rouen, France
| | | | - Philippe Cornu
- 14Neurosurgery, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | | | | | - Sorin Aldea
- 18Neurosurgery, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - François Proust
- 20Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - René Anxionnat
- 21Interventional Neuroradiology Department, University of Lorraine, Laboratory IADI INSERM U1254, CHRU Nancy, France
| | | | | | | | - Xavier Morandi
- 25Neurosurgery, Pontchaillou Hospital, CHU Rennes, France
| | - Hervé Brunel
- Departments of26Interventional Neuroradiology and
| | | | - Thomas Graillon
- 28Neurosurgery, La Timone Hospital, AP-HM, Marseille, France
| | - Emmanuel Chabert
- 29Interventional Neuroradiology Department, CHU Clermont-Ferrand, France
| | - Denis Herbreteau
- 30Interventional Neuroradiology Department, Bretonneau Hospital, Tours, France
| | - Hubert Desal
- 31Interventional Neuroradiology Department, CHU de Nantes, France
| | - Denis Trystram
- 32Interventional Neuroradiology Department, University of Paris, INSERM U1266, IPNP, GHU Paris, France
- 33Psychiatry and Neurosciences, Sainte-Anne Hospital, Paris, France
| | | | | | - Thanh N Nguyen
- Departments of36Radiology
- 37Neurology, and
- 38Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; and
| | | | - Guylaine Gevry
- 1Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Tim E Darsaut
- 5Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Boisseau W, Darsaut TE, Fahed R, Drake B, Lesiuk H, Rempel JL, Gentric JC, Ognard J, Nico L, Iancu D, Roy D, Weill A, Chagnon M, Zehr J, Lavoie P, Nguyen TN, Raymond J. Stent-Assisted Coiling in the Treatment of Unruptured Intracranial Aneurysms: A Randomized Clinical Trial. AJNR Am J Neuroradiol 2023; 44:381-389. [PMID: 36927759 PMCID: PMC10084896 DOI: 10.3174/ajnr.a7815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/16/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling may improve angiographic results of endovascular treatment of unruptured intracranial aneurysms compared with coiling alone, but this has never been shown in a randomized trial. MATERIALS AND METHODS The Stenting in the Treatment of Aneurysm Trial was an investigator-led, parallel, randomized (1:1) trial conducted in 4 university hospitals. Patients with intracranial aneurysms at risk of recurrence, defined as large aneurysms (≥10 mm), postcoiling recurrent aneurysms, or small aneurysms with a wide neck (≥4 mm), were randomly allocated to stent-assisted coiling or coiling alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS > 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that stent-assisted coiling would decrease treatment failures from 33% to 15%, requiring 200 patients. Primary analyses were intent to treat. RESULTS Of 205 patients recruited between 2011 and 2021, ninety-four were allocated to stent-assisted coiling and 111 to coiling alone. The primary outcome, ascertainable in 203 patients, was reached in 28/93 patients allocated to stent-assisted coiling (30.1%; 95% CI, 21.2%-40.6%) compared with 30/110 (27.3%; 95% CI, 19.4%-36.7%) allocated to coiling alone (relative risk = 1.10; 95% CI, 0.7-1.7; P = .66). Poor clinical outcomes (mRS >2) occurred in 8/94 patients allocated to stent-assisted coiling (8.5%; 95% CI, 4.0%-16.6%) compared with 6/111 (5.4%; 95% CI, 2.2%-11.9%) allocated to coiling alone (relative risk = 1.6; 95% CI, 0.6%-4.4%; P = .38). CONCLUSIONS The STAT trial did not show stent-assisted coiling to be superior to coiling alone for wide-neck, large, or recurrent unruptured aneurysms.
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Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery
| | - R Fahed
- Departments of Neurology (R.F.)
| | - B Drake
- Neurosurgery (B.D., H.L.), University of Ottawa, the Ottawa Hospital, Ottawa, Ontario, Canada
| | - H Lesiuk
- Neurosurgery (B.D., H.L.), University of Ottawa, the Ottawa Hospital, Ottawa, Ontario, Canada
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R.), University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J-C Gentric
- Department of Radiology (J.-C.G., J.O.), University Hospital of Brest, Brest, France
| | - J Ognard
- Department of Radiology (J.-C.G., J.O.), University Hospital of Brest, Brest, France
| | - L Nico
- Departement of Radiology (L.N.), Service of Interventional Neuroradiology, Centre Hospitalo-universitaire de Saint-Etienne, Saint-Etienne, France
| | - D Iancu
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Québec, Canada
| | - P Lavoie
- Department of Neurosurgery (P.L.), Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Canada
| | - T N Nguyen
- Departments of Neurology (T.N.N.)
- Radiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - J Raymond
- From the Department of Radiology (W.B., D.I., D.R., A.W., J.R.), Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
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Kerns RD, Davis AF, Fritz JM, Keefe FJ, Peduzzi P, Rhon DI, Taylor SL, Vining R, Yu Q, Zeliadt SB, George SZ. Intervention Fidelity in Pain Pragmatic Trials for Nonpharmacologic Pain Management: Nuanced Considerations for Determining PRECIS-2 Flexibility in Delivery and Adherence. THE JOURNAL OF PAIN 2023; 24:568-574. [PMID: 36574858 PMCID: PMC10079571 DOI: 10.1016/j.jpain.2022.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
Nonpharmacological treatments are considered first-line pain management strategies, but they remain clinically underused. For years, pain-focused pragmatic clinical trials (PCTs) have generated evidence for the enhanced use of nonpharmacological interventions in routine clinical settings to help overcome implementation barriers. The Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) framework describes the degree of pragmatism across 9 key domains. Among these, "flexibility in delivery" and "flexibility in adherence," address a key goal of pragmatic research by tailoring approaches to settings in which people receive routine care. However, to maintain scientific and ethical rigor, PCTs must ensure that flexibility features do not compromise delivery of interventions as designed, such that the results are ethically and scientifically sound. Key principles of achieving this balance include clear definitions of intervention core components, intervention monitoring and documentation that is sufficient but not overly burdensome, provider training that meets the demands of delivering an intervention in real-world settings, and use of an ethical lens to recognize and avoid potential trial futility when necessary and appropriate. PERSPECTIVE: This article presents nuances to be considered when applying the PRECIS-2 framework to describe pragmatic clinical trials. Trials must ensure that patient-centered treatment flexibility does not compromise delivery of interventions as designed, such that measurement and analysis of treatment effects is reliable.
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Affiliation(s)
- Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, Connecticut, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.
| | - Alison F Davis
- Pain Management Collaboratory, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Julie M Fritz
- Department of Physical Therapy & Athletic Training, College of Health, The University of Utah, Salt Lake City, Utah
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Peter Peduzzi
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, , New Haven, Connecticut
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Health Administration, Greater Los Angeles VA Health Care System, Los Angeles, California; Department of Medicine and Department of Health Policy and Management, UCLA, Los Angeles, California
| | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa
| | - Qilu Yu
- Office of Clinical and Regulatory Affairs, National Institutes of Health, National Center for Complementary and Integrative Health, Bethesda, Maryland
| | - Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington; Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Steven Z George
- Laszlo Ormandy Distinguished Professor, Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham North Carolina
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18
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Raymond J, Benomar A, Gentric JC, Magro E, Nico L, Bacchus E, Klink R, Iancu D, Weill A, Roy D, Bojanowski MW, Chaalala C, Eker O, Pelissou-Guyotat I, Piotin M, Aldea S, Barbier C, Gaberel T, Papagiannaki C, Derrey S, Nguyen TN, Abdalkader M, Cognard C, Januel AC, Sabatier JF, Jecko V, Barreau X, Costalat V, Le Corre M, Gauvrit JY, Morandi X, Biondi A, Thines L, Desal H, Bourcier R, Beaujeux R, Proust F, Viard G, Gevry G, Darsaut TE. Patient Selection in a Pragmatic Study on the Management of Patients with Brain Arteriovenous Malformations. World Neurosurg 2023; 172:e611-e624. [PMID: 36738962 DOI: 10.1016/j.wneu.2023.01.098] [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: 11/22/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is an all-inclusive pragmatic study comprising 2 randomized clinical trials (RCTs). Patients excluded from the RCTs are followed in parallel treatment and observation registries, allowing a comparison between RCT and registry patients. METHODS The first randomized clinical trial (RCT-1) offers 1:1 randomized allocation of intervention versus conservative management for patients with arteriovenous malformation (AVM). The second randomized clinical trial (RCT-2) allocates 1:1 pre-embolization or no pre-embolization to surgery or radiosurgery patients judged treatable with or without embolization. Characteristics of RCT patients are reported and compared to registry patients. RESULTS From June 2014 to May 2021, 1010 patients with AVM were recruited; 498 patients were observed and 373 were included in the treatment registries. Randomized allocation in RCT-1 was applied to 139 (26%) of the 512 patients (including 127 of 222 [57%] with unruptured AVMs) considered for curative treatment. RCT-1 AVM patients differed (in rupture status, Spetzler-Martin grade and baseline modified Rankin Score) from those in the observation or treatment registries (P < 0.001). Most patients had small (<3 cm; 71%) low-grade (Spetzler-Martin I-II; 64%) unruptured (91%) AVMs. The allocated management was conservative (n = 71) or curative (n = 68), using surgery (n = 39), embolization (n = 16), or stereotactic radiosurgery (n = 13). Pre-embolization was considered for 179/309 (58%) patients allocated/assigned to surgery or stereotactic radiosurgery; 87/179 (49%) were included in RCT-2. RCT-2 patient AVMs differed in size, eloquence and grade from patients of the pre-embolization registry (P < 0.01). Most had small (<3 cm in 82%) low-grade (83%) AVMs in non-eloquent brain (64%). CONCLUSIONS Patients included in the RCTs differ significantly from registry patients. Meaningful results can be obtained if multiple centers actively participate in the TOBAS RCTs.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - Anass Benomar
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | | | - Elsa Magro
- Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Lorena Nico
- Service de Neuroradiologie Interventionnelle, CHU Saint-Etienne, Saint-Étienne, France
| | - Emma Bacchus
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Laboratoire de Recherche en NeuroRadiologie Interventionnelle (NRI), Montreal, Quebec, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Omer Eker
- Service d'imagerie neurologique diagnostique et interventionnelle, Hôpital neurologique Pierre Wertheimer, Hospices civils de Lyon, Lyon, France
| | - Isabelle Pelissou-Guyotat
- Service de Neurochirurgie Tumorale et Vasculaire, Hôpital neurologique Pierre Wertheimer, Hospices civils de Lyon, Lyon, France
| | - Michel Piotin
- Service de Neuroradiologie Interventionnelle, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Sorin Aldea
- Service de Neurochirurgie, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Charlotte Barbier
- Service d'imagerie vasculaire et Interventionnelle, CHU Caen Normandie, Caen, France
| | - Thomas Gaberel
- Service de neurochirurgie, CHU Caen Normandie, Caen, France
| | | | - Stéphane Derrey
- Service de Neurochirurgie, Hôpital Charles Nicolle, CHU Rouen Normandie, Rouen France
| | - Thanh N Nguyen
- Department of Radiology, Department of Neurology, Department of Neurosurgery, Boston Medical Center, Boston University-School of Medicine, Boston, USA
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University-School of Medicine, Boston, USA
| | - Christophe Cognard
- Service de Neuroradiolgie diagnostique et thérapeutique, Hôpital Pierre-Paul Riquet, CHU de Toulouse, France
| | - Anne-Christine Januel
- Service de Neuroradiolgie diagnostique et thérapeutique, Hôpital Pierre-Paul Riquet, CHU de Toulouse, France
| | - Jean-François Sabatier
- Service de Neurochirurgie, Hôpital Pierre-Paul Riquet, CHU de Toulouse, Toulouse, France
| | - Vincent Jecko
- Service de Neurochirurgie A, Groupe Hospitalier Pellegrin, CHU Bordeaux, Bordeaux France
| | - Xavier Barreau
- Service de Neuroradiologie Diagnostique et Thérapeutique, Groupe Hospitalier Pellegrin, CHU Bordeaux, Bordeaux France
| | - Vincent Costalat
- Service de Neuroradiologie, CHU Montpellier, Montpellier, France
| | - Marine Le Corre
- Service de Neurochirurgie, CHU Montpellier, Montpellier, France
| | - Jean-Yves Gauvrit
- Service de neuroradiologie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Xavier Morandi
- Service de neurochirurgie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Alessandra Biondi
- Department of Interventional Neuroradiology, University Hospital Centre Besancon, Besancon, France
| | - Laurent Thines
- Department of Neurosurgery, University Hospital Jean Minjoz, Besançon, France
| | - Hubert Desal
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Rémy Beaujeux
- Service de Neuroradiologie Interventionnelle,Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - François Proust
- Service de Neurochirurgie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Guylaine Gevry
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Laboratoire de Recherche en NeuroRadiologie Interventionnelle (NRI), Montreal, Quebec, Canada
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Rheaume AR, Olijnyk L, Lecaros NE, Darsaut TE. Understanding the difference between theory and practice: The extracranial-intracranial bypass trials in prevention of ischemic stroke. Neurochirurgie 2023; 69:101407. [PMID: 36689827 DOI: 10.1016/j.neuchi.2023.101407] [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: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with atherosclerotic carotid or middle cerebral artery occlusions suffer ischemic events that might theoretically be preventable with a surgical extracranial-intracranial bypass, but theory by itself does not justify surgical interventions. METHODS We review landmark randomized trials on EC-IC bypass surgery for the treatment of ischemic stroke in patients with atherosclerotic stenoses or occlusions. RESULTS The initial EC-IC bypass trial from 1985 did not show any clinical benefit from surgery. The carotid occlusion surgery study (COSS) performed more than 20 years later included only patients highly selected to potentially benefit from bypass by using modern perfusion studies. While EC-IC bypasses were successfully created and they did improve cerebral perfusion, the COSS study also failed to show any clinical benefit to the participating patients. CONCLUSION Neurosurgical interventions must not only work in theory; they must improve patient outcomes in real practice.
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Affiliation(s)
- J Raymond
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada.
| | - A R Rheaume
- Division of neurosurgery, Department of surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - L Olijnyk
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada
| | - N E Lecaros
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada
| | - T E Darsaut
- Division of neurosurgery, Department of surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Olijnyk L, Lecaros NE, Rheaume AR, Darsaut TE. When successful surgery may not be beneficial to patients. Neurochirurgie 2023; 69:101406. [PMID: 36706512 DOI: 10.1016/j.neuchi.2023.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/26/2023]
Affiliation(s)
- J Raymond
- Centre hospitalier de l'université de Montreal, Montreal, Canada.
| | - L Olijnyk
- Centre hospitalier de l'université de Montreal, Montreal, Canada
| | - N E Lecaros
- Centre hospitalier de l'université de Montreal, Montreal, Canada
| | - A R Rheaume
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
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Darsaut TE, Collins J, Raymond J. Patients may be right: Clinical research should be designed in their best medical interest. Neurochirurgie 2023; 69:101391. [PMID: 36608449 DOI: 10.1016/j.neuchi.2022.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 01/05/2023]
Affiliation(s)
- T E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, 112 Street, 8440 Edmonton, Alberta, Canada
| | - J Collins
- Centre hospitalier de l'université de Montréal - CHUM, Department of Radiology, Service of Interventional Neuroradiology, 1000, St-Denis street room, D03-5462B Montreal, Canada
| | - J Raymond
- Centre hospitalier de l'université de Montréal - CHUM, Department of Radiology, Service of Interventional Neuroradiology, 1000, St-Denis street room, D03-5462B Montreal, Canada.
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Eneling J, Darsaut TE, Patel M, Raymond J. Understanding explanatory and pragmatic trials: Examples from randomized controlled trials on vertebroplasty. Neurochirurgie 2023; 69:101403. [PMID: 36566693 DOI: 10.1016/j.neuchi.2022.101403] [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: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To better understand the explanatory-pragmatic distinction in the design and interpretation of randomized controlled trials (RCTs). METHODS We review the explanatory-pragmatic distinction in clinical trial design. We use the PRECIS-2 tool to evaluate the trial design of selected RCTs on percutaneous vertebroplasty for osteoporotic vertebral compression fractures. We discuss difficulties in the selection of criteria and in the construction of PRECIS diagrams. We also examine how inconsistency in the selection of various items of trial design can cause confusion in the interpretation of results. RESULTS The selection of criteria and the scoring of multiple PRECIS domains were subjective and thus debatable. The pragmascope patterns of various vertebroplasty trials were heterogeneous. Many trials had both pragmatic and explanatory components. Some placebo-controlled trial goals seem to have been explanatory, but their design actually included enough pragmatic items such that the meaning of negative trial results remains ambiguous. CONCLUSION The results of a trial cannot be interpreted without understanding the various design choices made along the explanatory-pragmatic spectrum.
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Affiliation(s)
- J Eneling
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - M Patel
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
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Darsaut TE, Chagnon M, Raymond J. Reply. AJNR Am J Neuroradiol 2023; 44:E9-E10. [PMID: 36574315 PMCID: PMC9835901 DOI: 10.3174/ajnr.a7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- T E Darsaut
- Department of Surgery, Division of NeurosurgeryMackenzie Health Sciences CentreUniversity of Alberta HospitalEdmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and StatisticsUniversité de MontréalMontreal, Quebec, Canada
| | - J Raymond
- Department of Radiology, Service of Interventional NeuroradiologyCentre Hospitalier de l'Université de MontréalMontreal, Quebec, Canada
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Eneling J, Darsaut TE, Veilleux C, Raymond J. Understanding the choice of control group: A systematic review of vertebroplasty trials for osteoporotic vertebral compression fractures. Neurochirurgie 2023; 69:101401. [PMID: 36566694 DOI: 10.1016/j.neuchi.2022.101401] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To better understand the choice of the comparator intervention in the design of clinical trials and its impact on the meaning of results we review randomized trials on vertebroplasty. METHODS We conducted a systematic and narrative review of all randomized trials on vertebroplasty. Trials are categorized according to the comparator intervention (non-surgical management, placebo/sham vertebroplasty, and kyphoplasty). RESULTS All trials were too small to show a difference in objective clinical outcomes, and 20 of 23 RCTs used mean pain scores to compare interventions. Most trials comparing vertebroplasty with non-surgical management concluded that vertebroplasty was superior. Trials comparing kyphoplasty with vertebroplasty showed similar results for both interventions. However, 4 of 5 trials comparing vertebroplasty with placebo surgery failed to show a significant difference between groups. CONCLUSION The clinical results of an intervention cannot be interpreted without a comparison that involves a control group. The choice of comparator intervention can change the meaning of the trial. A large pragmatic trial, using hard clinical outcomes such as morbidity and mortality as a primary outcome measure, would be needed to assess the potential clinical benefits of vertebroplasty.
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Affiliation(s)
- J Eneling
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - C Veilleux
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Raymond J, Obaid S, Darsaut TE. Why are surgical trials so difficult to accomplish, and then considered so definitive? Neurochirurgie 2022; 68:560-561. [PMID: 35787923 DOI: 10.1016/j.neuchi.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 02/06/2023]
Affiliation(s)
- J Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - S Obaid
- Department of Neurosurgery, Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
| | - T E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Darsaut TE, Magro E, Bojanowski MW, Chaalala C, Nico L, Bacchus E, Klink R, Iancu D, Weill A, Roy D, Sabatier JF, Cognard C, Januel AC, Pelissou-Guyotat I, Eker O, Roche PH, Graillon T, Brunel H, Proust F, Beaujeux R, Aldea S, Piotin M, Cornu P, Shotar E, Gaberel T, Barbier C, Corre ML, Costalat V, Jecko V, Barreau X, Morandi X, Gauvrit JY, Derrey S, Papagiannaki C, Nguyen TN, Abdalkader M, Tawk RG, Huynh T, Viard G, Gevry G, Gentric JC, Raymond J. Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2022; 138:891-899. [PMID: 36087316 DOI: 10.3171/2022.7.jns22813] [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: 04/07/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).
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Affiliation(s)
- Tim E Darsaut
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Elsa Magro
- 2Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Michel W Bojanowski
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Lorena Nico
- 4Division of Interventional Neuroradiology, Department of Radiology, CHU Saint-Etienne, North Hospital, Saint-Etienne, France
| | - Emma Bacchus
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Daniela Iancu
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Jean-Francois Sabatier
- 7Department of Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Christophe Cognard
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Anne-Christine Januel
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | | | - Omer Eker
- 10Diagnostic and Interventional Neurological Imaging, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Thomas Graillon
- 12Department of Neurosurgery, Aix Marseille University, INSERM, AP-HM, MMG, UMR1251, Marmara Institute, La Timone Hospital, Marseille, France
| | - Hervé Brunel
- 13Department of Neuroradiology, La Timone Hospital, AP-HM, Marseille, France
| | - Francois Proust
- 14Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- 15Department of Interventional Neuroradiology, University Hospital of Strasbourg, Strasbourg, France
| | | | - Michel Piotin
- 17Interventional Radiology, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - Eimad Shotar
- 19Neuroradiology, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | - Charlotte Barbier
- 21Vascular and Interventional Imaging, CHU Caen Normandie, Caen, France
| | | | | | - Vincent Jecko
- 24Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | - Xavier Barreau
- 25Diagnostic and Therapeutic Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | | | - Jean-Yves Gauvrit
- 27Neuroradiology, Pontchaillou Hospital, Rennes University Hospital, Rennes, France
| | | | | | - Thanh N Nguyen
- Departments of30Radiology.,31Neurology, and.,32Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Thien Huynh
- 34Radiology, Mayo Clinic, Jacksonville, Florida
| | - Geraldine Viard
- 35Clinical Investigation Center, CHU Brest, Brest, France; and
| | - Guylaine Gevry
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- 36Department of Interventional Neuroradiology, Cavale Blanche Hospital, Brest University Hospital, Brest, France
| | - Jean Raymond
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada.,6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
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Raymond J, Iancu D, Boisseau W, Diestro JDB, Klink R, Chagnon M, Zehr J, Drake B, Lesiuk H, Weill A, Roy D, Bojanowski MW, Chaalala C, Rempel JL, O'Kelly C, Chow MM, Bracard S, Darsaut TE. Flow Diversion in the Treatment of Intracranial Aneurysms: A Pragmatic Randomized Care Trial. AJNR Am J Neuroradiol 2022; 43:1244-1251. [PMID: 35926886 PMCID: PMC9451626 DOI: 10.3174/ajnr.a7597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Flow diversion is a recent endovascular treatment for intracranial aneurysms. We compared the safety and efficacy of flow diversion with the alternative standard management options. MATERIALS AND METHODS A parallel group, prerandomized, controlled, open-label pragmatic trial was conducted in 3 Canadian centers. The trial included all patients considered for flow diversion. A Web-based platform 1:1 randomly allocated patients to flow diversion or 1 of 4 alternative standard management options (coiling with/without stent placement, parent vessel occlusion, surgical clipping, or observation) as prespecified by clinical judgment. Patients ineligible for alternative standard management options were treated with flow diversion in a registry. The primary safety outcome was death or dependency (mRS > 2) at 3 months. The composite primary efficacy outcome included the core lab-determined angiographic presence of a residual aneurysm, aneurysm rupture, progressive mass effect during follow-up, or death or dependency (mRS > 2) at 3-12 months. RESULTS Between May 2011 and November 2020, three hundred twenty-three patients were recruited: Two hundred seventy-eight patients (86%) had treatment randomly allocated (139 to flow diversion and 139 to alternative standard management options), and 45 (14%) received flow diversion in the registry. Patients in the randomized trial frequently had unruptured (83%), large (52% ≥10 mm) carotid (64%) aneurysms. Death or dependency at 3 months occurred in 16/138 patients who underwent flow diversion and 12/137 patients receiving alternative standard management options (relative risk, 1.33; 95% CI, 0.65-2.69; P = .439). A poor primary efficacy outcome was found in 30.9% (43/139) with flow diversion and 45.6% (62/136) of patients receiving alternative standard management options, with an absolute risk difference of 14.7% (95% CI, 3.3%-26.0%; relative risk, 0.68; 95% CI, 0.50-0.92; P = .014). CONCLUSIONS For patients with mostly unruptured, large, anterior circulation (carotid) aneurysms, flow diversion was more effective than the alternative standard management option in terms of angiographic outcome.
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Affiliation(s)
- J Raymond
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Iancu
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
- Departments of Radiology (D.I.)
| | - W Boisseau
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - J D B Diestro
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - R Klink
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - B Drake
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - H Lesiuk
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - A Weill
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Roy
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M W Bojanowski
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - C Chaalala
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | | | - C O'Kelly
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M M Chow
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - S Bracard
- Neuroradiology (S.B.), CHRU de Nancy, Nancy, Lorraine, France
| | - T E Darsaut
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Mtande TK, Nair G, Rennie S. Ethics and regulatory complexities posed by a pragmatic clinical trial: a case study from Lilongwe, Malawi. Malawi Med J 2022; 34:213-219. [PMID: 36406092 PMCID: PMC9641616 DOI: 10.4314/mmj.v34i3.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Pragmatic clinical trials generally rely on real world data and have the potential to generate real world evidence. This approach arose from concerns that many trial results did not adequately inform real world practice. However, maintaining the real world setting during the conduct of a trial and ensuring adequate protection for research participants can be challenging. Best practices in research oversight for pragmatic clinical trials are nascent and underdeveloped, especially in developing countries. Methods We use the PRECIS-2 tool to present a case study from Lilongwe in Malawi to describe ethical and regulatory challenges encountered during the conduct of a pragmatic trial and suggest possible solutions. Results In this article, we highlight the following six issues: (1) one public facility hosting several pragmatic trials within the same period; (2) research participants refusing financial incentives; (3) inadequate infrastructure and high workload to conduct research; (4) silos among partner organisations involved in delivery of health care; (5) individuals influencing the implementation of revised national guidelines; (6) difficulties with access to electronic medical records. Conclusion Multiple stakeholder engagement is critical to the conduct of pragmatic trials, and even with careful stakeholder engagement, continuous monitoring by gatekeepers is essential. In the Malawian context, active engagement of the district research committees can complement the work of the research ethics committees (RECs).
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Affiliation(s)
- Tiwonge Kumwenda Mtande
- Centre for Bioethics in Eastern and Southern Africa (CEBESA), Kamuzu University of Health Sciences, Malawi, Centre for Medical Ethics and Law (CMEL), Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gonasagrie Nair
- Centre for Medical Ethics and Law (CMEL), Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stuart Rennie
- Centre for Medical Ethics and Law (CMEL), Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, UNC Bioethics Center, Department of Social Medicine, University of North Carolina at Chapel Hill, USA
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Obaid S, Darsaut TE, Raymond J. Understanding the problems with recruitment in surgical randomized trials: A lesson from landmark trials on temporal lobe epilepsy. Neurochirurgie 2022; 68:612-617. [PMID: 35787925 DOI: 10.1016/j.neuchi.2022.06.005] [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: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical randomized trials are difficult to accomplish. One major problem is recruitment of a sufficient number of patients to address the clinical problem. METHODS We review the various ways patient recruitment in surgical RCTs can be promoted. We examine two landmark trials on the surgical treatment of temporal lobe epilepsy (TLE), one that was successful, and one which did not attain the target number of participants. DISCUSSION Both designs of the Canadian and American trials of surgery for TLE included a benefit to participants: the Canadian trial gave a chance to have immediate access to investigation and treatment, as compared to a 1 year delay (considered 'standard care' in that center), while the American trial offered free surgical management to both arms. Patients were recruited and treatments randomly allocated prior to knowing for certain whether they were surgical candidates or not. This design choice may have helped circumvent the 'equipoise problem'. The Canadian trial offered participation to drug-resistant patients that were already routinely referred to surgical centers, while the success of the American trial which limited recruitment to the early period of drug resistance was dependent on a change of practice of referring clinicians which did not materialize. CONCLUSION The surgical treatment of drug-resistant temporal lobe epilepsy has been validated using RCT methods. Ways to promote participation in surgical trials should be further investigated.
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Affiliation(s)
- S Obaid
- Department of Neurosurgery, Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
| | - T E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Raymond J, Magro E, Darsaut TE. Understanding burden of proof and equipoise in the design of pragmatic clinical trials: An example from a trial on brain arteriovenous malformations. Neurochirurgie 2022; 68:608-611. [PMID: 35787924 DOI: 10.1016/j.neuchi.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The burden of proof principle is rarely discussed and poorly understood, but central to the proper design of pragmatic clinical trials. A better understanding of the principle could play an important role in the re-introduction of scientific methods within practice and in revising fundamental problems with the current research-care separation. METHODS We analyze the design of the ARUBA trial on the management of unruptured brain arteriovenous malformations. We also review how the concept of clinical equipoise was introduced to address a misconceived problem of research ethics. RESULTS The ARUBA trial hypothesis in favour of conservative management of brain arteriovenous malformations failed to take into account the fact that the burden of proof was on surgery, endovascular treatment or radiation therapy. Thus, results remained inconclusive and other trials are needed. The equipoise notion fails to take into account that the burden of proof is on unvalidated medical or surgical interventions, if we want to provide outcome-based medical care that patients can trust. CONCLUSION The burden of proof principle is essential to properly design pragmatic trials. This principle also explains why in certain circumstances optimal care is a randomized care trial.
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Affiliation(s)
- J Raymond
- Department of radiology, service of neuroradiology, centre hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - E Magro
- Service de neurochirurgie, CHU Cavale-Blanche, Inserm UMR 1101 LaTIM, Brest, France
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie Health Sciences Centre, 8440 112St NW, Edmonton, Alberta, Canada
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Inter-rater reliability of the simplified Modified Rankin Scale as an outcome measure for treated cerebral aneurysm patients. Neurochirurgie 2022; 68:488-492. [PMID: 35662528 DOI: 10.1016/j.neuchi.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The modified Rankin scale (mRS) is commonly used as a clinical outcome measure in aneurysm trials, but inter-observer reliability in treated patients has not been tested. METHODS We reviewed the literature on inter-observer reliability studies of the mRS. Sixty patients with ruptured (n=47) or unruptured (n=13) aneurysms treated with endovascular methods (n=34) or surgical clipping (n=26) were independently evaluated by a neurosurgeon, a stroke neurologist, and a novice research assistant, and a simplified mRS score assigned. Results were analyzed using Gwet's AC1/2 reliability coefficients (KG). RESULTS No previous reports validating the reliability of the mRS in treated aneurysm patients were identified. Using the mRS 0-5, inter-rater agreement was almost perfect (KG=0.89 [0.86-0.93]). Agreement between raters remained almost perfect regardless of the rater's expertise. Agreement was almost perfect (KG=0.87 [0.77-0.96] when the mRS was dichotomized 0-2 vs 3-5, but fell to moderate when dichotomized 0-1 vs 2-5 (KG=0.59 (0.42-0.75). Agreement using the 0-2 vs 3-5 dichotomized mRS remained almost perfect for coiled (KG=0.90), clipped (KG=0.82), ruptured (KG=0.84), and unruptured (KG=0.95) aneurysms. Dichotomization of results at 0-1 vs 2-5 would have resulted in an (undesirable) significant difference in good outcomes between raters (P=.003), but not at 0-2 vs 3-5 (P=.52). CONCLUSION The simplified mRS appears to be a reliable clinical outcome measure for treated cerebral aneurysm patients. When needed, dichotomization is more reliable at mRS 0-2 vs 3-5 than at 0-1 vs 2-5. The simplified mRS is a promising tool in the functional assessment of aneurysm patients recruited in pragmatic care trials.
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Iancu D, Collins J, Farzin B, Darsaut TE, Eneling J, Boisseau W, Olijnyk L, Boulouis G, Chaalala C, Bojanowski MW, Weill A, Roy D, Raymond J. Recruitment in a pragmatic randomized trial on the management of unruptured intracranial aneurysms. World Neurosurg 2022; 163:e413-e419. [PMID: 35395427 DOI: 10.1016/j.wneu.2022.03.142] [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: 01/22/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The Comprehensive Aneurysm Management (CAM) study is a pragmatic trial designed to manage UIA patients within a care research framework. METHOD CAM is an all-inclusive study. Management options are allocated according to an algorithm combining pre-randomization and clinical judgment. Eligible patients are offered 1:1 randomized allocation of intervention versus conservative management and 1:1 randomization allocation of surgical versus endovascular treatment. Ineligible patients are registered. The primary outcome is survival without dependency (mRS<3) at 10 years. All UIA patients at one center are reported. RESULTS Between February 2020 and July 2021, 403 UIA patients were recruited: 179 (44%) in one of the RCTs and 224 (56%) in one of the registries. Conservative management was recommended for 205/403 patients (51%); of 198 (49%) patients considered for curative treatment, 159 (80%) were randomly allocated conservative (n=81) or curative treatment (n=78). These patients were younger and had larger aneurysms than those in the observation registry (P = .004). In 39/198 patients (20%), conservative management was not considered reasonable (17 patients were recommended endovascular, 2 surgery, and 20 the RCT comparing endovascular with surgical treatment). In total, 70 patients were recruited in the RCT comparing surgery and endovascular treatment. After informed discussion at time of consent, 141/159 patients (89%) agreed with the randomly allocated management plan, while 11% crossed-over to the alternative management option. CONCLUSION CAM was successfully integrated into routine practice. Meaningful conclusions can be obtained if multiple centers actively participate in the trial.
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Affiliation(s)
- Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Jennifer Collins
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Behzad Farzin
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Edmonton, Alberta, Canada
| | - Johanna Eneling
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Leonardo Olijnyk
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Grégoire Boulouis
- Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada.
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Raymond J, Long H, Darsaut T. Pragmatic trials can address diagnostic controversies: recent lessons from gestational diabetes. Trials 2022; 23:246. [PMID: 35365186 PMCID: PMC8973943 DOI: 10.1186/s13063-022-06169-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/08/2022] [Indexed: 11/27/2022] Open
Abstract
Objective The aim of the paper is to discuss how a pragmatic definition could change our conception of diagnosis, using gestational diabetes mellitus (GDM) as an example. Study design We review the diagnostic controversy that followed an observational study showing a linear relationship between maternal glycaemia and adverse pregnancy outcomes and the resolution proposed 15 years later by a recent pragmatic trial comparing two screening approaches (one- vs two-step) with different diagnostic thresholds. Results The pragmatic trial involved approximately 24,000 women. The one-step screening strategy using lower GDM thresholds diagnosed twice as many women with GDM, but pregnancy outcomes were not different. We examine how the pragmatic approach integrates research into practice and defines the meaning of a diagnosis according to patient outcomes. The approach is ethically and scientifically sound as compared to the previous methodology, where observational research separated from care gave a theoretical definition of GDM that may have misled medical practice for two decades. Conclusion Pragmatic research integrated into practice can revolutionize our conception of medical diagnosis in the best medical interest of patients.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), University of Montreal, Montreal, Quebec, H2X 0C1, Canada.
| | - Hélène Long
- Department of Medicine, Division of Endocrinology and Metabolism, Laval Health and Social Services Centres, Laval, Canada
| | - Tim Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Darsaut TE. Understanding how to move from dogmatic to outcome-based neurosurgical care: Lessons from past surgical studies on ruptured aneurysm patients. Neurochirurgie 2022; 68:478-482. [DOI: 10.1016/j.neuchi.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Olijnyk L, Darsaut TE, Öhman J, Raymond J. Understanding the importance of the primary trial hypothesis: The randomized trial on the timing of ruptured aneurysm surgery. Neurochirurgie 2022; 68:474-477. [DOI: 10.1016/j.neuchi.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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Medical care research, bureaucracy and funding: New hope to resolve the impasse. Neurochirurgie 2021; 68:260-261. [PMID: 35039163 DOI: 10.1016/j.neuchi.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 11/21/2022]
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Patel M, Au K, Easaw JC, Davis FG, Young K, Mehta V, Bowden GN, Keough MB, Sankar T, Scholtes F, Chagnon M, L'Espérance G, Yuan Y, Gevry G, Raymond J, Darsaut TE. Repeat Resection in Recurrent Glioblastoma (3rGBM) Trial: a randomized care trial. Neurochirurgie 2021; 68:262-266. [PMID: 34534565 DOI: 10.1016/j.neuchi.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/30/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The prognosis for patients with recurrent glioblastoma (GBM) is dismal, and the question of repeat surgery at time of recurrence is common. Re-operation in the management of these patients remains controversial, as there is no randomized evidence of benefit. An all-inclusive pragmatic care trial is needed to evaluate the role of repeat resection. METHODS 3rGBM is a multicenter, pragmatic, prospective, parallel-group randomized care trial, with 1:1 allocation to repeat resection or standard care with no repeat resection. To test the hypothesis that repeat resection can improve overall survival by at least 3 months (from 6 to 9 months), 250 adult patients with prior resection of pathology-proven glioblastoma for whom the attending surgeon believes repeat resection may improve quality survival will be enrolled. A surrogate measure of quality of life, the number of days outside of hospital/nursing/palliative care facility, will also be compared. Centers are invited to participate without financial compensation and without contracts. Clinicians may apply to local authorities to approve an investigator-led in-house trial, using a common protocol, web-based randomization platform, and simple standardized case report forms. DISCUSSION The 3rGBM trial is a modern transparent care research framework with no additional risks, tests, or visits other than what patients would encounter in normal care. The burden of proof remains on repeat surgical management of recurrent GBM, because this management has yet to be shown beneficial. The trial is designed to help patients and surgeons manage the uncertainty regarding optimal care. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique identifier: NCT04838782.
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Affiliation(s)
- Mukt Patel
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
| | - Karolyn Au
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
| | - Jacob C Easaw
- Department of Oncology, Faculty of Medicine, Cross Cancer Institute, 11560 University Ave, University of Alberta, T6G 1Z2 Edmonton, Alberta, Canada
| | - Faith G Davis
- School of Public Health, University of Alberta, T6G 2R3 Edmonton, Alberta, Canada
| | - Kelvin Young
- Department of Oncology, Faculty of Medicine, Cross Cancer Institute, 11560 University Ave, University of Alberta, T6G 1Z2 Edmonton, Alberta, Canada
| | - Vivek Mehta
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
| | - Greg N Bowden
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
| | - Tejas Sankar
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
| | - Felix Scholtes
- Departments of Neuroanatomy and Neurosurgery, University of Liège and CHU Liège, Liège, Belgium
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Pavillon André-Aisenstadt (AA-5190),2920 chemin de la Tour, H3T 1J4 Montreal, Quebec, Canada
| | - Georges L'Espérance
- Dying with Dignity Canada, and Division of Neurosurgery, Department of Surgery, Université de Montréal, Canada
| | - Yan Yuan
- School of Public Health, University of Alberta, T6G 2R3 Edmonton, Alberta, Canada
| | - Guylaine Gevry
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 St-Denis street, room D03.5462B, H2X 0C1 Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 St-Denis street, room D03.5462B, H2X 0C1 Montreal, Quebec, Canada
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 112 St NW, T6G 2B7 Edmonton, Alberta, Canada
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