Clinical Research Methodology 1

Tenofovir versus entecavir on the prognosis of hepatitis B virus-related hepatocellular carcinoma: a reconstructed individual patient data meta-analysis

Background: Hepatitis B, often leading to Hepatocellular carcinoma (HCC), poses a major global health challenge. While Tenofovir (TDF) and Entecavir (ETV) are potent treatments, their comparative effectiveness in improving recurrence-free survival (RFS) and overall survival (OS) rates in HBV-related HCC is not well-established. Methods: We conducted an individual patient data meta-analysis using survival data from randomized trials and high-quality propensity score-matched studies to compare the impact of Tenofovir (TDF) and Entecavir (ETV) on RFS and OS in HBV-related HCC patients. Data from six databases and gray literature up to 30 August 2023, were analyzed, utilizing Kaplan-Meier curves, stratified Cox models, and shared frailty models for survival rate assessment and to address between-study heterogeneity. The study employed restricted mean survival time analysis to evaluate differences in RFS and OS between TDF-treated and ETV-treated patients. Additionally, landmark analyses compared early (<2 years) and late (≥2 years) tumor recurrence in these cohorts. Results: This study incorporated seven research articles, covering 4,602 patients with HBV-related HCC (2,082 on TDF and 2,520 on ETV). Within the overall cohort, TDF recipients demonstrated significantly higher RFS (p = 0.042) and OS (p < 0.001) than those on ETV. The stratified Cox model revealed significantly improved OS for the TDF group compared to the ETV group (hazard ratio, 0.756; 95% confidence interval, 0.639-0.896; p = 0.001), a result corroborated by the shared frailty model. Over a follow-up period of 1-8 years, no significant difference was noted in the mean time to death between the TDF and ETV groups. The rates of early recurrence did not significantly differ between the groups (p = 0.735). However, TDF treatment was significantly associated with a reduced risk of late recurrence compared to ETV (p < 0.001). In the HCC resection subgroup, the disparities in OS, early, and late recurrence rates between the two treatments paralleled those seen in the overall cohort. Conclusion: Compared to ETV, TDF may enhance OS and reduce late tumor recurrence risk in HBV-related HCC patients receiving curative treatment. However, there was no statistically significant distinction in the timing of tumor recurrence and mortality between patients administered TDF and those prescribed ETV. Systematic Review Registration: http://www.crd.york.ac.uk/prospero/.

The causal effect of exposure to air pollution on risk of adverse pregnancy outcomes: A two-sample Mendelian randomisation study

BACKGROUND

Epidemiological studies have examined the relation between air pollution (NOx, NO2, PM2.5, PM2.5-10, and PM10) and adverse pregnancy outcomes (APOs). There's increasing evidence that air pollution increases the risk of APOs. However, the results of these studies are controversial, and the causal relation remains uncertain. We aimed to assess whether a genetic causal link exists between air pollution and APOs and the potential effects of this relation.

METHODS

A novel two-sample Mendelian randomisation (MR) study used pooled data from a large-scale complete genome correlation study. The primary analysis method was inverse variance weighting (IVW), which explored the expose-outcome relationship for assessing single nucleotide polymorphisms (SNPs) associated with air pollution. Further sensitivity analysis, including MR-PRESSO, MR-Egger regression, and leave-one analysis, was used to test the consistency of the results.

RESULTS

There was a significant correlation between air pollution-related SNPs and APOs. A robust causal link was found between genetic susceptibility to air pollution and APOs.

CONCLUSIONS

Our MR analysis reveals a genetic causal relation between air pollution and APOs, which may help provide new insights into further mechanisms and clinical studies in air pollution-mediated APOs.

Effects of an Integrated Geriatric-Orthopedic Co-management (InGerO) on the Treatment of Older Orthopedic Patients with Native and Periprosthetic Joint Infections

In view of our aging society, co-management with a geriatrician is becoming increasingly important. While such collaborations have been working successfully in trauma surgery for years, it is still unclear whether they are also helpful for non-trauma patients in orthopedics. The aim of this study was to investigate the effect of such a cooperation in orthopedic non-trauma patients with native and periprosthetic joint infections on the basis of five key areas.A retrospective observational study as a before and after comparison was used to compare routine data from patients with and without orthogeriatric co-management after nontraumatic surgery. Eligible patients for the study were 70 years and older, had a diagnosis of hip, knee, or shoulder infection, and had been hospitalized for at least 14 days. Co-management consisted of close follow-up by a geriatrician, Comprehensive Geriatric Assessment, and "complex early geriatric rehabilitation". The comparison group received therapy as usual, without a geriatrician and without "complex early geriatric rehabilitation". Special attention was paid to delirium, pain, mobility, postoperative complications, and renal function.Analysis was carried out with 59 patients "with" and 63 "without" geriatric co-management. In the co-management group, delirium was detected significantly more often (p < 0.001), significantly lower pain intensities were measured at the time of discharge (p < 0.001), transfer ability had clearly improved more (p = 0.04), and renal function was more frequently noted (p = 0.04). No significant differences were found with respect to principal diagnoses, surgical procedures performed, complication rates, pressure ulcer and delirium incidence, operative revisions, or length of inpatient stay.Orthogeriatric co-management in orthopedic patients with native and periprosthetic joint infections and nontraumatic surgery appears to have positive impacts on recognition and treatment of delirium, pain management, transfer performance, and attention to renal function. Further studies should follow in order to conclusively assess the value of such co-management in orthopedic nontraumatic surgery patients.

Anesthesia and Oncology: Friend or Foe?

Cancer is a leading cause of death, and surgery is an important treatment modality. Laboratory research and retrospective studies have raised the suspicion that the choice of anesthetics for cancer surgery might affect the course of cancerous disease. The aim of this review is to provide a critical overview of the current state of knowledge. Inhalational anesthesia with volatiles or total intravenous anesthesia (TIVA) with propofol are the two most commonly used anesthetic techniques. Most data comparing volatile anesthetics with TIVA is from either in vitro or retrospective studies. Although conflicting, data shows a trend towards favoring propofol. Opioids are commonly used in anesthesia. Data on potential effects of opioids on growth and recurrence of cancer are scarce and conflicting. Preclinical studies have shown that opioids stimulate cancer growth through the µ-opioid receptor. Opioids also act as immunosuppressants and, therefore, have the potential to facilitate metastatic spread. However, the finding of an adverse effect of opioids on tumor growth and cancer recurrence by some retrospective studies has not been confirmed by prospective studies. Regional anesthesia has not been found to have a beneficial effect on the outcome of surgically treated cancer patients, but prospective studies are scarce. Local anesthetics might have a beneficial effect, as observed in animal and in vitro studies. However, prospective clinical studies strongly question such an effect. Blood products, which may be needed during extensive cancer surgery suppress the immune system, and data strongly suggest a negative impact on cancer recurrence. The potential effects of other commonly used anesthetic agents on the outcome of cancer patients have not been sufficiently studied for drawing valid conclusions. In conclusion, laboratory data and most retrospective studies suggest a potential advantage of TIVA over inhalational anesthesia on the outcome of surgical cancer patients, but prospective, randomized studies are missing. Given the state of weak scientific evidence, TIVA may be used as the preferred type of anesthesia unless there is an individual contraindication against it. Studies on the effects of other drugs frequently used in anesthesia are limited in number and quality, and have found conflicting results.

Leg length discrepancy: A systematic review on the validity and reliability of clinical assessments and imaging diagnostics used in clinical practice

BACKGROUND

A variety of assessments to determine leg length discrepancy (LLD) is used in clinical practice and evidence about validity and reliability may differ.

OBJECTIVE

The objective of this systematic review was to identify and describe the validity and reliability of different assessments and imaging diagnostics for the determination of LLD.

MATERIALS AND METHODS

The review was conducted following the recommendations of Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The databases Medline (PubMed) and Index to Chiropractic Literature were systematically searched. Studies regarding clinical assessments and imaging diagnostics for the diagnosis of LLD, which reported the clinimetric properties for assessment of LLD, were included and screened for methodological quality using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool for validity studies and the Quality Appraisal of Diagnostic Reliability (QAREL) tool for reliability studies.

RESULTS

Thirty-seven articles on clinical assessments and 15 studies on imaging diagnostics met the eligibility criteria. Thirteen studies on the validity of clinical assessments and six studies on the validity of imaging diagnostics had a low risk of bias and low concerns regarding applicability for all domains. One study on the reliability of clinical assessments and one study on the reliability of imaging diagnostics had a low risk of bias. Main limitations were, that an analysis of sensitivity and specificity was only performed in a few studies and that a valid reference standard was lacking in numerous studies on clinical assessments.

CONCLUSIONS

For the clinical assessment of LLD, the block test appears to be the most useful method. Full-length standing anteroposterior radiography seems to be the most valid and reliable method and may be used as global reference standard to measure the anatomic LLD when comparing clinical methods and imaging diagnostics.

A comparison of liver MRI and contrast enhanced CT as standard workup before treatment for rectal cancer in usual care - a Retrospective Study

BACKGROUND

The liver is the most common site for rectal cancer metastases. Recommended standard pre-treatment workup has involved computed tomography (CT) for abdominal metastases. However, few hospitals have replaced this with magnetic resonance imaging (MRI).

INTRODUCTION

The aim of this study was to compare MRI with CT as an index examination of the liver in the pre-treatment workup in usual care. The primary endpoint was the need for supplementary liver investigations.

METHOD

Consecutive patients from two hospitals during 2013-2015 were identified in the Regional Swedish Colorectal Cancer Register and included in this retrospective study. Hospital records and radiology reports were reviewed. Inconclusive reports were re-evaluated by two radiologists.

RESULT

A total of 320 patients were included, and 293 were available for analysis. Some 175 and 118 patients had undergone CT and MRI, respectively, as their index pretreatment liver examination. Thirty-four (19.4%) in the CT group and 6 (5.1%) patients in the MRI group underwent supplementary liver investigation due to inconclusive index examination (RR 3.82, 95% CI: 1.66;8.81, p=0.0017). Median time (q1;q3) from index examination to start of treatment was 50 (36;68) days in the CT group and 34 (27;45) days in the MRI group.

CONCLUSION

This retrospective study of two modalities within usual care found that MRI of the liver as index radiological workup before treatment for rectal cancer was associated with fewer supplementary liver investigations and a shorter time to start treatment. Based on these findings, a prospective trial should be undertaken before implementing MRI as a standard.

A Comparison of CT Manifestations between Coronavirus Disease 2019 (COVID-19) and Other Types of Viral Pneumonia

BACKGROUND

Though imaging manifestations of COVID-19 and other types of viral pneumonia are similar, their clinical treatment methods differ. Accurate, non-invasive diagnostic methods using CT imaging can help developing an optimal therapeutic regimen for both conditions.

OBJECTIVES

To compare the initial CT imaging features in COVID-19 with those in other types of viral pneumonia.

METHODS

Clinical and imaging data of 51 patients with COVID-19 and 69 with other types of viral pneumonia were retrospectively studied. All significant imaging features (Youden index >0.3) were included for constituting the combined criteria for COVID-19 diagnosis, composed of two or more imaging features with a parallel model. McNemar's chi-square test or Fisher's exact test was used to compare the validity indices (sensitivity and specificity) among various criteria.

RESULTS

Ground glass opacities (GGO) dominated density, peripheral distribution, unilateral lung, clear margin of lesion, rounded morphology, long axis parallel to the pleura, vascular thickening, and crazy-paving pattern were more common in COVID-19 (p <0.05). Consolidation-dominated density, both central and peripheral distribution, bilateral lung, indistinct margin of lesion, tree-in-bud pattern, mediastinal or hilar lymphadenectasis, pleural effusion, and pleural thickening were more common in other types of viral pneumonia (p < 0.05). GGO-dominated density or long axis parallel to the pleura (with the highest sensitivity), and GGO-dominated density or long axis parallel to the pleura or vascular thickening (with the highest specificity) are good combined criteria of COVID-19.

CONCLUSION

The initial CT imaging features are helpful for differential diagnosis between COVID-19 and other types of viral pneumonia.

Myocardial Injury After Noncardiac Surgery: Preoperative, Intraoperative, and Postoperative Aspects, Implications, and Directions

Myocardial injury after noncardiac surgery (MINS) differs from myocardial infarction in being defined by troponin elevation apparently from cardiac ischemia with or without signs and symptoms. Such myocardial injury is common, silent, and strongly associated with mortality. MINS is usually asymptomatic and only detected by routine troponin monitoring. There is currently no known safe and effective prophylaxis for perioperative myocardial injury. However, appropriate preoperative screening may help guide proactive postoperative preventative actions. Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. Hypotension is common and largely undetected in the postoperative general care floor setting, and independently associated with myocardial injury and mortality. Critical care patients are especially sensitive to hypotension, and the risk appears to be present at blood pressures previously regarded as normal. Tachycardia appears to be less important. Available information suggests that clinicians would be prudent to avoid perioperative hypotension.

Transcatheter indirect mitral annuloplasty induces annular and left atrial remodelling in secondary mitral regurgitation

Aims

Mitral annuloplasty using the Carillon Mitral Contour System (CMCS) reduces secondary mitral regurgitation (SMR) and leads to reverse left ventricular remodelling. The aim of this study was to evaluate the effect of the CMCS on the mitral valve annulus (MA) and left atrial volume (LAV).

Methods and results

We retrospectively evaluated the data of all patients treated with the CMCS at our centre. Using transthoracic echocardiography, MA diameters were assessed by measuring the anterolateral to posteromedial extend (ALPM) and the anterior to posterior (AP) dimensions, respectively. Also, LAV and left ventricular end‐diastolic volume (LVEDV) were assessed. Patients were examined at three time points: baseline, at 20–60 days (30dFUP), and at 9–15 months (1yFUP), using paired analysis. From July 2014 until March 2019, 75 cases of severe SMR were treated using CMCS. Cases in which other devices were used in combination (COMBO therapy, n = 35) or in which the device could not be implanted (implant failure, n = 3) were excluded, leaving 37 patients in the present analysis. Analysis at 30dFUP showed a significant reduction of 16% in the mean ALPM diameter (7.27 ± 5.40 mm) and 15% in the AP diameter (6.57 ± 5.33 mm). Analysis of LAV also showed a significant reduction of 21% (36.61 ± 82.67 mL), with no significant change in LVEDV. At 1yFUP, the reduction of both the mean ALPM diameter of 14% (6.24 ± 5.70 mm) and the mean AP diameter of 12% (5.46 ± 4.99 mm) remained significant and stable. The reduction in LAV was also maintained at 23% (37.03 ± 56.91 mL). LAV index was significantly reduced by 17% at 30dFUP (15.44 ± 40.98 mL/m²) and by 13% at 1yFUP (11.56 ± 31.87 mL/m²), respectively. LVEDV index showed no significant change at 30dFUP and a non‐significant 10% reduction at 1yFUP (17.75 ± 58.79 mL/m²).

Conclusions

The CMCS successfully treats symptomatic SMR with a stable reduction of not only the AP diameter of the MA, but the current study also demonstrates an additional reduction of the ALPM dimension at both 30dFUP and 1yFUP. We have also shown for the first time that LAV and LAV index are significantly reduced at both 30dFUP and 1yFUP and a non‐significant positive remodelling of the LVEDV. This positive left atrial remodelling has not been looked for and demonstrated in earlier randomized studies of CMCS.

Novel Clinical Trial Designs to Improve the Efficiency of Research

SUMMARY

Large randomized trials provide the highest level of clinical evidence. However, enrolling large numbers of randomized patients across numerous study sites is expensive and often takes years. There will never be enough conventional clinical trials to address the important questions in medicine. Efficient alternatives to conventional randomized trials that preserve protections against bias and confounding are thus of considerable interest. A common feature of novel trial designs is that they are pragmatic and facilitate enrollment of large numbers of patients at modest cost. This article presents trial designs including cluster designs, real-time automated enrollment, and practitioner-preference approaches. Then various adaptive designs that improve trial efficiency are presented. And finally, the article discusses the advantages of embedding randomized trials within registries.

Catastrophizing, pain, and functional outcomes for children with chronic pain: a meta-analytic review

Pediatric chronic pain is associated with numerous negative outcomes including increased physical disability, increased rates of depression and anxiety, and decreased quality of life (QOL). Pain catastrophizing-broadly conceptualized as including rumination, magnification, and helplessness cognitions surrounding one's pain-has been linked with poor functional outcomes in children with chronic pain. Pain catastrophizing in pediatric chronic pain is often considered a key factor on which to focus treatment efforts. However, absent a systematic review that integrates the relevant literature, this call for routine assessment and targeted treatment may be premature. This study aimed to: (1) meta-analytically quantify the relationship between catastrophizing and pain and functional/psychosocial outcomes (functional disability/physical functioning, anxiety, depression, and QOL) in children with chronic pain, and (2) examine potential moderators of these relationships. Using a random-effects model, a total of 111 effect sizes from 38 studies were analyzed. Effect sizes ranged from medium to large, with anxiety, depression, and QOL demonstrating a strong association with catastrophizing. Pain intensity and physical disability had a moderate association with catastrophizing. These relationships were robust, minimizing potential publication bias. None of the examined moderators were significant. The strong relationships found between catastrophizing and anxiety, depression, and QOL suggest that successfully intervening on catastrophizing could have far reaching implications in improving pain outcomes in pediatric chronic pain.

Clinical trials

Clinical trials can be used to generate data on safety, efficacy, and/or effectiveness of treatments. They can be classified based on their purpose, phase, or design. Key components of clinical trial design include: identifying the study question and population; clearly defining the treatment and comparison groups; choosing the method of treatment group allocation; defining the primary and secondary outcomes; performing a power analysis; outlining an analytic plan; and reporting results. Critical issues to consider when either designing a trial or interpreting the results of a trial include evaluating the validity and generalizability of the results and assessing the appropriateness of the control group. Designing and implementing clinical trials in pediatric surgery is challenging, but well-constructed and executed trials are instrumental in improving clinical care.

Perioperative myocardial injury and the contribution of hypotension

Mortality in the month following surgery is about 1000 times greater than anesthesia-related intraoperative mortality, and myocardial injury appears to be the leading cause. There is currently no known safe prophylaxis for postoperative myocardial injury, but there are strong associations among hypotension and myocardial injury, renal injury, and death. During surgery, the harm threshold is a mean arterial pressure of about 65 mmHg. In critical care units, the threshold appears to be considerably greater, perhaps 90 mmHg. The threshold triggering injury on surgical wards remains unclear but may be in between. Much of the association between hypotension and serious complications surely results from residual confounding, but sparse randomized data suggest that at least some harm can be prevented by intervening to limit hypotension. Reducing hypotension may therefore improve perioperative outcomes.

Prospective associations of poor diet quality with long-term incidence of protein-energy malnutrition in community-dwelling older adults: the Health, Aging, and Body Composition (Health ABC) Study

Background

Protein-energy malnutrition (PEM) is a major problem in older adults. Whether poor diet quality is an indicator for the long-term development of PEM is unknown.

Objective

The aim was to determine whether poor diet quality is associated with the incidence of PEM in community-dwelling older adults.

Design

We used data on 2234 US community-dwelling older adults aged 70-79 y of the Health, Aging, and Body Composition (Health ABC) Study. In 1998-1999, dietary intake over the preceding year was measured by using a Block food-frequency questionnaire. Indicators of diet quality include the Healthy Eating Index (HEI), energy intake, and protein intake. Outcomes were determined annually by using measured weight and height and included the following: 1) incident PEM [body mass index (in kg/m2) <20, involuntary weight loss of ≥5% in the preceding year at any follow-up examination, or both] and 2) incident persistent PEM (having PEM at 2 consecutive follow-up examinations). Associations of indicators of diet quality with 4-y and 3-y incidence of PEM and persistent PEM, respectively, were examined by multivariable Cox regression analyses.

Results

The quality of the diet, as assessed with the HEI, was rated as "poor" for 6.4% and as "needs improvement" for 73.0% of the participants. During follow-up, 24.9% of the participants developed PEM and 8.5% developed persistent PEM. A poor HEI score was not associated with incident PEM or persistent PEM. Lower baseline energy intake was associated with a lower incidence of PEM (HR per 100-kcal/d lower intake: 0.98; 95% CI: 0.97, 0.99) and persistent PEM (HR: 0.97; 95% CI: 0.95, 0.99), although lower baseline protein intake was observed to be associated with a higher incidence of persistent PEM (HR per 10-g/d lower intake: 1.15; 95% CI: 1.03, 1.29).

Conclusions

These findings do not indicate that a poor diet quality is a risk factor for the long-term development of PEM in community-dwelling older adults, although there is an indication that lower protein intake is associated with higher PEM risk.

Ion channels and neuronal hyperexcitability in chemotherapy-induced peripheral neuropathy; cause and effect?

Abstract

Cancer is the second leading cause of death worldwide and is a major global health burden. Significant improvements in survival have been achieved, due in part to advances in adjuvant antineoplastic chemotherapy. The most commonly used antineoplastics belong to the taxane, platinum, and vinca alkaloid families. While beneficial, these agents are frequently accompanied by severe side effects, including chemotherapy-induced peripheral neuropathy (CPIN). While CPIN affects both motor and sensory systems, the majority of symptoms are sensory, with pain, tingling, and numbness being the predominant complaints. CPIN not only decreases the quality of life of cancer survivors but also can lead to discontinuation of treatment, thereby adversely affecting survival. Consequently, minimizing the incidence or severity of CPIN is highly desirable, but strategies to prevent and/or treat CIPN have proven elusive. One difficulty in achieving this goal arises from the fact that the molecular and cellular mechanisms that produce CPIN are not fully known; however, one common mechanism appears to be changes in ion channel expression in primary afferent sensory neurons. The processes that underlie chemotherapy-induced changes in ion channel expression and function are poorly understood. Not all antineoplastic agents directly affect ion channel function, suggesting additional pathways may contribute to the development of CPIN Indeed, there are indications that these drugs may mediate their effects through cellular signaling pathways including second messengers and inflammatory cytokines. Here, we focus on ion channelopathies as causal mechanisms for CPIN and review the data from both pre-clinical animal models and from human studies with the aim of facilitating the development of appropriate strategies to prevent and/or treat CPIN.