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Ames SG, Salvi A, Lin A, Malveau S, Mann NC, Jenkins PC, Hansen M, Papa L, Schmitz S, Sabogal C, Newgard CD. Timing and causes of death to 1 year among children presenting to emergency departments. Acad Emerg Med 2024; 31:555-563. [PMID: 38499441 PMCID: PMC11168880 DOI: 10.1111/acem.14875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/05/2023] [Accepted: 12/31/2023] [Indexed: 03/20/2024]
Abstract
BACKGROUND AND OBJECTIVES A better characterization of deaths in children following emergency care is needed to inform timely interventions. This study aimed to describe the timing, location, and causes of death to 1 year among a cohort of injured and medically ill children. METHODS We conducted a retrospective cohort study of children <18 years requiring emergency care in six states from January 1, 2012, through December 31, 2017, with follow-up through December 31, 2018, for patients who were not discharged from the emergency department (ED). In this cohort, 1-year mortality, time to death within 1 year, and causes of death were assessed from ED, inpatient, and vital status records. RESULTS There were 546,044 children during the 6-year period. The 1-year mortality rate was 2.2% (n = 1356) for injured children and 1.4% (n = 6687) for medically ill children. Matched death certificates were available for 861 (63.5%) of 1356 deaths in the injury cohort and for 4712 (70.5%) of 6687 deaths in the medical cohort. Among deaths in the injury cohort, 1274 (94.0%) occurred in the ED or hospital. The most common causes of death were motor vehicle collisions, firearm injuries, and pedestrian injuries. Among the 6687 deaths in the medical cohort, 5081 (76.0%) children died in the ED or hospital (primarily in the ED) and 1606 (24.0%) occurred after hospital discharge. The most common causes of death were sudden infant death syndrome, suffocation and drowning, and congenital conditions. CONCLUSIONS The 1-year mortality of children presenting to an ED is 2.2% for injured children and 1.4% for medically ill children with most deaths occurring in the ED. Future interventional trials, quality improvement efforts, and health policy focused in the ED could have the potential to improve outcomes of pediatric patients.
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Affiliation(s)
- Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Sabrina Schmitz
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Cesar Sabogal
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
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Katheria AC, Schmölzer GM, Law B, Yoder BA, Clark E, El-Naggar W, Morales A, Dorner RA, Mooso B, Rich W, Vora F, Finer N. Parental perspectives on a trial using waived informed consent at birth. J Perinatol 2024; 44:415-418. [PMID: 38129598 DOI: 10.1038/s41372-023-01853-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/24/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To determine parental perspectives in a trial with waived consent. STUDY DESIGN Anonymous survey of birth parents with term infants who were randomized using a waiver of consent, administered after infant discharge. RESULTS 121 (11%) survey responses were collected. Of the 121 responding parents 111 (92%) reported that this form of consent was acceptable and 116 (96%) reported feeling comfortable having another child participate in a similar study. 110 (91%) respondents reported that they both understood the information provided in the consent process and had enough time to consider participation. Four percent had a negative opinion on the study's effect on their child's health. CONCLUSIONS Most responding parents reported both acceptability of this study design in the neonatal period and that the study had a positive effect on their child's health. Future work should investigate additional ways to involve parents and elicit feedback on varied methods of pediatric consent.
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Affiliation(s)
- Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA.
| | | | - Brenda Law
- University of Alberta, Edmonton, AB, Canada
| | | | - Erin Clark
- University of Utah, Salt Lake City, UT, USA
| | | | - Ana Morales
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Rebecca A Dorner
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Benjamin Mooso
- University of California at San Diego, San Diego, CA, USA
| | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Farha Vora
- Loma Linda University, Loma Linda, CA, USA
| | - Neil Finer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
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3
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Katheria A, Schmolzer G, Law B, Yoder B, Clark E, El-Naggar W, Morales A, Dorner R, Mooso B, Rich W, Vora F, Finer N. Parental Perspectives on a Trial Using Waived Informed Consent at Birth. RESEARCH SQUARE 2023:rs.3.rs-3487820. [PMID: 37961362 PMCID: PMC10635395 DOI: 10.21203/rs.3.rs-3487820/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Objectives To determine parental perspectives in a trial with waived consent. Study Design Biological parents of non-vigorous term infants randomized using a waiver of consent for a delivery room intervention completed an anonymous survey after discharge. Results 121 survey responses were collected. Most responding parents reported that this form of consent was acceptable (92%) and that they would feel comfortable having another child participate in a similar study (96%). The majority (> 90%) also reported that the information provided after randomization was clear to understand future data collection procedures. Four percent had a negative opinion on the study's effect on their child's health. Conclusions The majority of responding parents reported both acceptability of this study design in the neonatal period and that the study had a positive effect on their child's health. Future work should investigate additional ways to involve parents and elicit feedback on varied methods of pediatric consent.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Wade Rich
- Sharp Mary Birch Hospital for Women & Newborns
| | - Farha Vora
- Loma Linda University Children's Hospital
| | - Neiil Finer
- Sharp Mary Birch Hospital for Women & Newborns
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4
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Walsh S, Pan S, Sheng Y, Kloprogge F, Standing JF, Anderson BJ, Ramnarayan P. Optimising intravenous salbutamol in children: a phase 2 study. Arch Dis Child 2023; 108:316-322. [PMID: 36581395 DOI: 10.1136/archdischild-2022-324008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 12/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The β2-agonists such as salbutamol are the mainstay of asthma management. Pharmacokinetic-pharmacodynamic (PKPD) models to guide paediatric dosing are lacking. We explored the relationship between salbutamol dose, serum concentration, effectiveness and adverse effects in children by developing a PKPD model. DESIGN A prospective cohort study of children admitted to hospital with acute asthma, who received intravenous salbutamol. SETTING Children were recruited in two cohorts: the emergency departments of two London hospitals or those retrieved by the Children's Acute Transport Service to three London paediatric intensive care units. PATIENTS Patients were eligible if aged 1-15 years, admitted for acute asthma and about to receive or receiving intravenous salbutamol. INTERVENTIONS Treatment was according to local policy. Serial salbutamol plasma levels were taken. Effectiveness measurements were recorded using the Paediatric Asthma Severity Score (PASS). Toxicity measurements included lactate, pH, glucose, heart rate, blood pressure and arrhythmias. PKPD modelling was performed with non-linear mixed-effect models. MAIN OUTCOMES Fifty-eight children were recruited with 221 salbutamol concentration measurements from 54 children. Median (range) age was 2.9 (1.1-15.2) years, and weight was 13.6 (8-57.3) kg. Ninety-five PASS measurements and 2078 toxicity measurements were obtained. RESULTS A two-compartment PK model adequately described the time course of salbutamol-plasma concentrations. An EMAX (maximum drug effect) concentration-effect relationship described PASS and toxicity measures. PKPD simulations showed an infusion of 0.5 µg/kg/min (maximum 20 µg/min) for 4 hours after bolus achieves >90% maximal bronchodilation for 12 hours. CONCLUSIONS A paediatric PKPD model for salbutamol is described. An infusion of 0.5 µg/kg/min after bolus achieves effective bronchodilation. Higher rates are associated with greater tachycardia and hyperglycaemia.
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Affiliation(s)
- Sandra Walsh
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Shan Pan
- Infection, Immunity and Inflammation Section, UCL Great Ormond Street Institute of Child Health Library, London, UK
| | - Yucheng Sheng
- Infection, Immunity and Inflammation Section, UCL Great Ormond Street Institute of Child Health Library, London, UK
| | - Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Joe F Standing
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Colacci M, Raissi A, Bhasin A, Branfield Day L, Bregger M, Carpenter T, Castellucci L, Cheung AM, Dragoi L, Dunbar-Yaffe R, Fidler L, Fowler R, Gosset A, Hensel R, Herridge M, Hussein H, Kapral M, Munshi L, Quinn K, Razak F, Roza da Costa B, Soong C, Tang T, Venus K, Verma A, Fralick M. Understanding how deferred consent affects patient characteristics and outcomes: an exploratory analysis of a clinical trial of prone positioning for COVID-19. J Clin Epidemiol 2023; 153:102-105. [PMID: 36273771 PMCID: PMC9706549 DOI: 10.1016/j.jclinepi.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Michael Colacci
- General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Ajay Bhasin
- Department of Medicine, Division of Hospital Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Leora Branfield Day
- General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Bregger
- Department of Medicine, Division of Hospital Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Travis Carpenter
- Division of General Internal Medicine, St Joseph's Health Centre, Unity Health Toronto, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lana Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Angela M Cheung
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laura Dragoi
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Richard Dunbar-Yaffe
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Lee Fidler
- Division of Respirology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rob Fowler
- University Health Network, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Alexi Gosset
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Hensel
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Margaret Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Haseena Hussein
- Department of Medicine, William Osler Health System, Brampton, Ontario, Canada
| | - Moira Kapral
- General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laveena Munshi
- Mount Sinai Hospital, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Kieran Quinn
- Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fahad Razak
- Division of General Internal Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Bruno Roza da Costa
- The Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christine Soong
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health, Toronto, Ontario, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Kevin Venus
- University Health Network, Division of General Internal Medicine and Geriatrics, Toronto, Ontario, Canada
| | - Amol Verma
- Division of General Internal Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Fralick
- Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Chang I, Thomas K, O'Neill Gutierrez L, Peters S, Agbeko R, Au C, Draper E, Jones GAL, Major LE, Orzol M, Pappachan J, Ramnarayan P, Ray S, Sadique Z, Gould DW, Harrison DA, Rowan KM, Mouncey PR, Peters MJ. Protocol for a Randomized Multiple Center Trial of Conservative Versus Liberal Oxygenation Targets in Critically Ill Children (Oxy-PICU): Oxygen in Pediatric Intensive Care. Pediatr Crit Care Med 2022; 23:736-744. [PMID: 35699737 PMCID: PMC9426735 DOI: 10.1097/pcc.0000000000003008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Oxygen administration is a fundamental part of pediatric critical care, with supplemental oxygen offered to nearly every acutely unwell child. However, optimal targets for systemic oxygenation are unknown. Oxy-PICU aims to evaluate the clinical effectiveness and cost-effectiveness of a conservative peripheral oxygen saturation (Sp o2 ) target of 88-92% compared with a liberal target of more than 94%. DESIGN Pragmatic, open, multiple-center, parallel group randomized control trial with integrated economic evaluation. SETTING Fifteen PICUs across England, Wales, and Scotland. PATIENTS Infants and children age more than 38 week-corrected gestational age to 16 years who are accepted to a participating PICU as an unplanned admission and receiving invasive mechanical ventilation with supplemental oxygen for abnormal gas exchange. INTERVENTION Adjustment of ventilation and inspired oxygen settings to achieve an Sp o2 target of 88-92% during invasive mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Randomization is 1:1 to a liberal Sp o2 target of more than 94% or a conservative Sp o2 target of 88-92% (inclusive), using minimization with a random component. Minimization will be performed on: age, site, primary reason for admission, and severity of abnormality of gas exchange. Due to the emergency nature of the treatment, approaching patients for written informed consent will be deferred to after randomization. The primary clinical outcome is a composite of death and days of organ support at 30 days. Baseline demographics and clinical status will be recorded as well as daily measures of oxygenation and organ support, and discharge outcomes. This trial received Health Research Authority approval on December 23, 2019 (reference: 272768), including a favorable ethical opinion from the East of England-Cambridge South Research Ethics Committee (reference number: 19/EE/0362). Trial findings will be disseminated in national and international conferences and peer-reviewed journals.
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Affiliation(s)
- Irene Chang
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Lauran O'Neill Gutierrez
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sam Peters
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Rachel Agbeko
- Department of Paediatric Intensive Care, Great North Children's Hospital, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Carly Au
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Elizabeth Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Gareth A L Jones
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Marzena Orzol
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - John Pappachan
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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7
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Ramnarayan P, Richards-Belle A, Drikite L, Saull M, Orzechowska I, Darnell R, Sadique Z, Lester J, Morris KP, Tume LN, Davis PJ, Peters MJ, Feltbower RG, Grieve R, Thomas K, Mouncey PR, Harrison DA, Rowan KM. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial. JAMA 2022; 328:162-172. [PMID: 35707984 PMCID: PMC9204623 DOI: 10.1001/jama.2022.9615] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known. OBJECTIVE To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022. INTERVENTIONS Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299). MAIN OUTCOMES AND MEASURES The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation. RESULTS Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI -10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, -3 days [95% CI, -5.1 to -1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, -7.6 days [95% CI, -13.2 to -1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]). CONCLUSIONS AND RELEVANCE Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support. TRIAL REGISTRATION ISRCTN.org Identifier: ISRCTN60048867.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, England
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Izabella Orzechowska
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | | | - Kevin P. Morris
- Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Salford, England
| | - Peter J. Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Mark J. Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, England
- University College London Great Ormond Street Institute of Child Health, London, England
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
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8
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Fitzpatrick A, Wood F, Shepherd V. Trials using deferred consent in the emergency setting: a systematic review and narrative synthesis of stakeholders' attitudes. Trials 2022; 23:411. [PMID: 35578362 PMCID: PMC9109432 DOI: 10.1186/s13063-022-06304-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute conditions often lack the capacity to provide informed consent, and narrow therapeutic windows mean there is no time to seek consent from surrogates prior to treatment being commenced. One method to enable the inclusion of this study population in emergency research is through recruitment without prior consent, often known as 'deferred consent'. However, empirical studies have shown a large disparity in stakeholders' opinions regarding this enrolment method. This systematic review aimed to understand different stakeholder groups' attitudes to deferred consent, particularly in relation to the context in which deferred consent might occur. METHODS Databases including MEDLINE, EMCare, PsychINFO, Scopus, and HMIC were searched from 1996 to January 2021. Eligible studies focussed on deferred consent processes for adults only, in the English language, and reported empirical primary research. Studies of all designs were included. Relevant data were extracted and thematically coded using a narrative approach to 'tell a story' of the findings. RESULTS Twenty-seven studies were included in the narrative synthesis. The majority examined patient views (n = 19). Data from the members of the public (n = 5) and health care professionals (n =5) were also reported. Four overarching themes were identified: level of acceptability of deferred consent, research-related factors influencing acceptability, personal characteristics influencing views on deferred consent, and data use after refusal of consent or participant death. CONCLUSIONS This review indicates that the use of deferred consent would be most acceptable to stakeholders during low-risk emergency research with a narrow therapeutic window and where there is potential for patients to benefit from their inclusion. While the use of narrative synthesis allowed assessment of the included studies, heterogeneous outcome measures meant that variations in study results could not be reliably attributed to the different trial characteristics. Future research should aim to develop guidance for research ethics committees when reviewing trials using deferred consent in emergency research and investigate more fully the views of healthcare professionals which to date have been explored less than patients and members of the public. Trial registration PROSPERO CRD42020223623.
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Affiliation(s)
| | - Fiona Wood
- Division of Population Medicine and PRIME Centre Wales, University Hospital of Wales, Cardiff University, 8th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS Wales
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9
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Ramnarayan P, Richards-Belle A, Drikite L, Saull M, Orzechowska I, Darnell R, Sadique Z, Lester J, Morris KP, Tume LN, Davis PJ, Peters MJ, Feltbower RG, Grieve R, Thomas K, Mouncey PR, Harrison DA, Rowan KM. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Following Extubation on Liberation From Respiratory Support in Critically Ill Children: A Randomized Clinical Trial. JAMA 2022; 327:1555-1565. [PMID: 35390113 PMCID: PMC8990361 DOI: 10.1001/jama.2022.3367] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE The optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known. OBJECTIVE To evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway pressure (CPAP), on time to liberation from respiratory support. DESIGN, SETTING, AND PARTICIPANTS This was a pragmatic, multicenter, randomized, noninferiority trial conducted at 22 pediatric intensive care units in the United Kingdom. Six hundred children aged 0 to 15 years clinically assessed to require noninvasive respiratory support within 72 hours of extubation were recruited between August 8, 2019, and May 18, 2020, with last follow-up completed on November 22, 2020. INTERVENTIONS Patients were randomized 1:1 to start either HFNC at a flow rate based on patient weight (n = 299) or CPAP of 7 to 8 cm H2O (n = 301). MAIN OUTCOMES AND MEASURES The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio (HR) of 0.75. There were 6 secondary outcomes, including mortality at day 180 and reintubation within 48 hours. RESULTS Of the 600 children who were randomized, 553 children (HFNC, 281; CPAP, 272) were included in the primary analysis (median age, 3 months; 241 girls [44%]). HFNC failed to meet noninferiority, with a median time to liberation of 50.5 hours (95% CI, 43.0-67.9) vs 42.9 hours (95% CI, 30.5-48.2) for CPAP (adjusted HR, 0.83; 1-sided 97.5% CI, 0.70-∞). Similar results were seen across prespecified subgroups. Of the 6 prespecified secondary outcomes, 5 showed no significant difference, including the rate of reintubation within 48 hours (13.3% for HFNC vs 11.5 % for CPAP). Mortality at day 180 was significantly higher for HFNC (5.6% vs 2.4% for CPAP; adjusted odds ratio, 3.07 [95% CI, 1.1-8.8]). The most common adverse events were abdominal distension (HFNC: 8/281 [2.8%] vs CPAP: 7/272 [2.6%]) and nasal/facial trauma (HFNC: 14/281 [5.0%] vs CPAP: 15/272 [5.5%]). CONCLUSIONS AND RELEVANCE Among critically ill children requiring noninvasive respiratory support following extubation, HFNC compared with CPAP following extubation failed to meet the criterion for noninferiority for time to liberation from respiratory support. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN60048867.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Izabella Orzechowska
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Kevin P. Morris
- Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Lyvonne N. Tume
- School of Health & Society, University of Salford, Salford, United Kingdom
| | - Peter J. Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Mark J. Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- University College London Great Ormond St Institute of Child Health, London, United Kingdom
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
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10
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van den Bos N, van den Berg SA, Caupain CM, Pols JA, van Middelaar T, Chalos V, Dippel DW, Roos YB, Kappelhof M, Nederkoorn PJ. Patient and proxies' attitudes towards deferred consent in randomised trials of acute treatment for stroke: A qualitative survey. Eur Stroke J 2022; 6:395-402. [PMID: 35342818 PMCID: PMC8948520 DOI: 10.1177/23969873211057421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Deferral of consent for participation in a clinical study is a relatively novel procedure, in which informed consent is obtained after randomisation and study treatment. Deferred consent can be used in emergency situations, where small therapeutic time windows limit possibilities for patients to provide informed consent. We aimed to investigate patients' or their proxies' experiences and opinions regarding deferred consent in acute stroke randomised trials. Patients and methods For this qualitative study, Dutch Collaboration for New Treatments of Acute Stroke (CONTRAST) trial participants were selected. Study participants were either patients or their proxies who provided consent and were selected with theoretical sampling based on patient characteristics. Semi-structured interviews were conducted face-to-face or by telephone. Themes and subthemes were iteratively defined. Results Twenty of the 23 interviewed participants (16 patients and 7 proxies) considered deferred consent acceptable. The received study treatment and consent conversation were remembered by 18 participations, although the concept of randomisation and treatment comparison were generally not well understood. Sixteen participants felt capable of overseeing the decision to give deferred consent. Distress in the first days after stroke, lack of understanding and neurological deficits were reasons for feeling incapable of providing consent. Four participants would have preferred a different timing of the consent conversation, of whom two prior to treatment. Conclusion Our study found that deferred consent was considered acceptable by most study participants who provided consent for acute stroke randomised trials. Though they felt capable, the recall and comprehension of consent were overall limited.
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Affiliation(s)
- Noa van den Bos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Catalina Mm Caupain
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeannette Aj Pols
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anthropology, University of Amsterdam, The Netherlands
| | - Tessa van Middelaar
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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11
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Sloss S, Dawson JA, McGrory L, Rafferty AR, Davis PG, Owen LS. Observational study of parental opinion of deferred consent for neonatal research. Arch Dis Child Fetal Neonatal Ed 2021; 106:258-264. [PMID: 33127737 DOI: 10.1136/archdischild-2020-319974] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/11/2020] [Accepted: 09/29/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the opinions of parents of newborns following their infant's enrolment into a neonatal research study through the process of deferred consent. DESIGN Mixed-methods, observational study, interviewing 100 parents recently approached for deferred consent. SETTING Tertiary-level neonatal intensive care unit, Melbourne, Australia. RESULTS All 100 parents interviewed had consented to the study/studies using deferred consent; 62% had also experienced a prospective neonatal consent process. Eighty-nine per cent were 'satisfied' with the deferred consent process. The most common reason given for consenting was 'to help future babies'. Negative comments regarding deferred consent mostly related to the timing of the consent approach, and some related to a perceived loss of parental rights. A deferred approach was preferred by 51%, 24% preferred a prospective approach and 25% were unsure. Those who thought prospective consent would not have been preferable cited impaired decision-making, inappropriate timing of an approach before birth and their preference for removal of the decision-making burden via deferred consent. Seventy-seven per cent thought they would have given the same response if approached prospectively; those who would have declined reported that a prospective approach under stressful conditions was unwelcome and too overwhelming. CONCLUSION In our sample, 89% of parents of infants enrolled in neonatal research using deferred consent considered it acceptable and half would not have preferred prospective consent. The ability to make a more considered decision under less stressful circumstances was key to the acceptability of deferred consent.
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Affiliation(s)
- Samantha Sloss
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Anne Dawson
- Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Lorraine McGrory
- Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia
| | | | - Peter G Davis
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia .,Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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12
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Weiss SL, Fitzgerald JC, Balamuth F. Let Us Not Forget Early Mortality in Pediatric Sepsis. Pediatr Crit Care Med 2021; 22:434-436. [PMID: 33790212 PMCID: PMC8023721 DOI: 10.1097/pcc.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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13
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Johnson KT, Görges M, Murthy S. Characteristics and Timing of Mortality in Children Dying With Infections in North American PICUs. Pediatr Crit Care Med 2021; 22:365-379. [PMID: 33591070 DOI: 10.1097/pcc.0000000000002667] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the characteristics and timing of death of children with severe infections who die during PICU admission. DESIGN We analyzed demographics, timing of death, diagnoses, and common procedures in a large cohort obtained from the Virtual Pediatrics Systems database, focusing on early deaths (< 1 d). SETTING Clinical records were prospectively collected in 130 PICUs across North America. PATIENTS Children admitted between January 2009 and December 2014 with at least one infection-related diagnosis at time of death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis included data from 106,464 children admitted to PICUs. The 4,240 children (4%) who died were older than PICU survivors. The median (interquartile range) duration in PICU prior to death was 7.1 days (2.1-21.3 d), with 635 children (15%) dying early (< 1 d of PICU admission). Children who died early were older, more likely to have septic shock, and more likely to have received cardiopulmonary resuscitation than those who died later. Withdrawal of care was less likely in early deaths compared with later deaths. After adjusting for age, sex, sepsis severity, procedures (including cardiopulmonary resuscitation and heart, lung, and renal support), and number of admissions contributed per PICU, it was found that children admitted from the emergency department, inpatient floors, or referring hospitals had significantly greater risk of early death compared with children admitted from the operating room. CONCLUSIONS A substantial proportion of children admitted to PICU with severe infections die early and differ from those dying later in diagnoses, procedures, and admitting location. The emergency department is a key source of critically ill patients. Understanding characteristics of early deaths may yield recruitment considerations for clinical trials enrolling children at high risk of early death.
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Affiliation(s)
- K Taneille Johnson
- Department of Pediatrics, Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
- Research Institute, BC Children's Hospital (BCCH), Vancouver, BC, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
- Research Institute, BC Children's Hospital (BCCH), Vancouver, BC, Canada
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14
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Vohra S, Reilly M, Rac VE, Bhaloo Z, Zayak D, Wimmer J, Vincer M, Ferrelli K, Kiss A, Soll R, Dunn M. Differences in demographics and outcomes based on method of consent for a randomised controlled trial on heat loss prevention in the delivery room. Arch Dis Child Fetal Neonatal Ed 2021; 106:118-124. [PMID: 33234598 DOI: 10.1136/archdischild-2020-319045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Informed consent is standard in research. International guidelines allow for research without prior consent in emergent situations, such as neonatal resuscitation. Research without prior consent was incorporated in the Vermont Oxford Network Heat Loss Prevention Trial. We evaluated whether significant differences in outcomes exist based on the consent method. DESIGN Subgroup analysis of infants enrolled in a randomised controlled trial conducted from 2004 to 2010. SETTING A multicentre trial with 38 participating centres. PARTICIPANTS Infants born 24-27 weeks of gestation. 3048 infants assessed, 2231 excluded due to fetal congenital anomalies, failure to obtain consent or gestation less than 24 weeks. 817 randomised, 4 withdrew consent, total of 813 analysed. MAIN OUTCOME MEASURE The difference in mortality between consent groups. RESULTS No significant differences were found in mortality at 36 weeks (80.2%, 77.4%, p=0.492) or 6 months corrected gestational age (80.7%, 79.7%, p=0.765). Infants enrolled after informed consent were more likely to have mothers who had received antenatal steroids (95.2%, 84.0%, p<0.0001). They also had significantly higher Apgar scores at 1 (5.0, 4.4, p=0.019), 5 (7.3, 6.7, p=0.025) and 10 min (7.5, 6.3, p=0.0003). CONCLUSIONS AND RELEVANCE Research without prior consent resulted in the inclusion of infants with different baseline characteristics than those enrolled after informed consent. There were no significant differences in mortality. Significantly higher Apgar scores in the informed consent group suggest that some of the sicker infants would have been excluded from enrolment under informed consent. Research without prior consent should be considered in neonatal resuscitation research.
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Affiliation(s)
- Sunita Vohra
- Pediatrics, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Maureen Reilly
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Valeria E Rac
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zafira Bhaloo
- Pediatrics, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Denise Zayak
- Newborn-Perinatal Medicine, Vermont Oxford Network, Burlington, Vermont, USA
| | - John Wimmer
- Cone Health, Women's Hospital of Greensboro, Greensboro, North Carolina, USA
| | - Michael Vincer
- Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karla Ferrelli
- Newborn-Perinatal Medicine, Vermont Oxford Network, Burlington, Vermont, USA
| | - Alex Kiss
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Roger Soll
- Newborn-Perinatal Medicine, Vermont Oxford Network, Burlington, Vermont, USA.,Pediatrics, University of Vermont, Burlington, Vermont, USA
| | - Michael Dunn
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Pediatrics, University of Toronto, Toronto, Ontario, Canada
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15
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Pirson FAVA, Hinsenveld WH, Goldhoorn RJB, Staals J, de Ridder IR, van Zwam WH, van Walderveen MAA, Lycklama À Nijeholt GJ, Uyttenboogaart M, Schonewille WJ, van der Lugt A, Dippel DWJ, Roos YBWEM, Majoie CBLM, van Oostenbrugge RJ. MR CLEAN-LATE, a multicenter randomized clinical trial of endovascular treatment of acute ischemic stroke in The Netherlands for late arrivals: study protocol for a randomized controlled trial. Trials 2021; 22:160. [PMID: 33627168 PMCID: PMC7903604 DOI: 10.1186/s13063-021-05092-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 02/02/2021] [Indexed: 11/28/2022] Open
Abstract
Background Endovascular therapy (EVT) for acute ischemic stroke due to proximal occlusion of the anterior intracranial circulation, started within 6 h from symptom onset, has been proven safe and effective. Recently, EVT has been proven effective beyond the 6-h time window in a highly selected population using CT perfusion or MR diffusion. Unfortunately, these imaging modalities are not available in every hospital, and strict selection criteria might exclude patients who could still benefit from EVT. The presence of collaterals on CT angiography (CTA) may offer a more pragmatic imaging criterion that predicts possible benefit from EVT beyond 6 h from time last known well. The aim of this study is to assess the safety and efficacy of EVT for patients treated between 6 and 24 h from time last known well after selection based on the presence of collateral flow. Methods The MR CLEAN-LATE trial is a multicenter, randomized, open-label, blinded endpoint trial, aiming to enroll 500 patients. We will investigate the efficacy of EVT between 6 and 24 h from time last known well in acute ischemic stroke due to a proximal intracranial anterior circulation occlusion confirmed by CTA or MRA. Patients with any collateral flow (poor, moderate, or good collaterals) on CTA will be included. The inclusion of poor collateral status will be restricted to a maximum of 100 patients. In line with the current Dutch guidelines, patients who fulfill the characteristics of included patients in DAWN and DEFUSE 3 will be excluded as they are eligible for EVT as standard care. The primary endpoint is functional outcome at 90 days, assessed with the modified Rankin Scale (mRS) score. Treatment effect will be estimated with ordinal logistic regression (shift analysis) on the mRS at 90 days. Secondary endpoints include clinical stroke severity at 24 h and 5–7 days assessed by the NIHSS, symptomatic intracranial hemorrhage, recanalization at 24 h, follow-up infarct size, and mortality at 90 days, Discussion This study will provide insight into whether EVT is safe and effective for patients treated between 6 and 24 h from time last known well after selection based on the presence of collateral flow on CTA. Trial registration NL58246.078.17, ISRCTN19922220, Registered on 11 December 2017 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05092-0.
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Affiliation(s)
- F A V Anne Pirson
- Department of Neurology, Maastricht University Medical Center, Postbus 5800, Maastricht, 6202 AZ, The Netherlands
| | - Wouter H Hinsenveld
- Department of Neurology, Maastricht University Medical Center, Postbus 5800, Maastricht, 6202 AZ, The Netherlands
| | - Robert-Jan B Goldhoorn
- Department of Neurology, Maastricht University Medical Center, Postbus 5800, Maastricht, 6202 AZ, The Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Postbus 5800, Maastricht, 6202 AZ, The Netherlands
| | - Inger R de Ridder
- Department of Neurology, Maastricht University Medical Center, Postbus 5800, Maastricht, 6202 AZ, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Maarten Uyttenboogaart
- Department of Neurology and Department of Radiology, University of Groningen, Groningen, The Netherlands
| | | | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center, Postbus 5800, Maastricht, 6202 AZ, The Netherlands.
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16
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MR CLEAN-NO IV: intravenous treatment followed by endovascular treatment versus direct endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion-study protocol for a randomized clinical trial. Trials 2021; 22:141. [PMID: 33588908 PMCID: PMC7885482 DOI: 10.1186/s13063-021-05063-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Background Endovascular treatment (EVT) has greatly improved the prognosis of acute ischemic stroke (AIS) patients with a proximal intracranial large vessel occlusion (LVO) of the anterior circulation. Currently, there is clinical equipoise concerning the added benefit of intravenous alteplase administration (IVT) prior to EVT. The aim of this study is to assess the efficacy and safety of omitting IVT before EVT in patients with AIS caused by an anterior circulation LVO. Methods MR CLEAN-NO IV is a multicenter randomized open-label clinical trial with blinded outcome assessment (PROBE design). Patients ≥ 18 years of age with a pre-stroke mRS < 3 with an LVO confirmed on CT angiography/MR angiography eligible for both IVT and EVT are randomized to receive either IVT (0.9 mg/kg) followed by EVT, or direct EVT in a 1:1 ratio. The primary objective is to assess superiority of direct EVT. Secondarily, non-inferiority of direct EVT compared to IVT before EVT will be explored. The primary outcome is the score on the modified Rankin Scale at 90 days. Ordinal regression with adjustment for prognostic variables will be used to estimate treatment effect. Secondary outcomes include reperfusion graded with the eTICI scale after EVT and stroke severity (National Institutes of Health Stroke Scale) at 24 h. Safety outcomes include intracranial hemorrhages scored according to the Heidelberg criteria. A total of 540 patients will be included. Discussion IVT prior to EVT might facilitate early reperfusion before EVT or improved reperfusion rates during EVT. Conversely, among other potential adverse effects, the increased risk of bleeding could nullify the beneficial effects of IVT. MR CLEAN-NO IV will provide insight into whether IVT is still of added value in patients eligible for EVT. Trial registration www.isrctn.com: ISRCTN80619088. Registered on 31 October 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05063-5.
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17
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Harley A, George S, King M, Phillips N, Keijzers G, Long D, Gibbons K, Bellomo R, Schlapbach LJ. Early Resuscitation in Paediatric Sepsis Using Inotropes - A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED): Study Protocol and Analysis Plan. Front Pediatr 2021; 9:663028. [PMID: 34136441 PMCID: PMC8200662 DOI: 10.3389/fped.2021.663028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/21/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction: Septic shock in children still carries substantial mortality and morbidity. While resuscitation with 40-60 mL/kg intravenous fluid boluses remains a cornerstone of initial resuscitation, an increasing body of evidence indicates potential for harm related to high volume fluid administration. We hypothesize that a protocol on early use of inotropes in children with septic shock is feasible and will lead to less fluid bolus use compared to standard fluid resuscitation. Here, we describe the protocol of the Early Resuscitation in Paediatric Sepsis Using Inotropes - A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED). Methods and analysis: The RESPOND ED study is an open label randomised controlled, two arm, multicentre pilot study conducted at four specialised paediatric Emergency Departments. Forty children aged between 28 days and 18 years treated for presumed septic shock will be randomized in a 1:1 ratio to early inotropes vs. standard fluid resuscitation. Early inotrope treatment is defined as the commencement of a continuous intravenous adrenaline infusion after 20 mL/kg fluid bolus resuscitation. Standard fluid resuscitation is defined as delivery of 40 to 60 mL/kg fluid bolus resuscitation prior to commencement of inotropes. In addition to feasibility outcomes, survival free of organ dysfunction censored at 28 days will be assessed as the main clinical outcome. The study cohort will be followed up at 28 days, and at 6 months post enrolment to assess quality of life and functional status. Biobanking nested in the study cohort will be performed to enable ancillary biomarker studies. Ethics and dissemination: The trial has ethical clearance (Children's Health Queensland, Brisbane, HREC/18/QCHQ/49168) and is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12619000828123). Enrolment commenced on July 21st, 2019. The primary manuscript will be submitted for publication in a peer-reviewed journal. Trial Registration: Australian and New Zealand Clinical Trials Registry, ACTRN12619000828123.
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Affiliation(s)
- Amanda Harley
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Shane George
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Megan King
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia.,Emergency Department Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Natalie Phillips
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Emergency Department Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia.,School of Medicine, Griffith University, Southport, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Southport, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, VIC, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Pediatric and Neonatal Intensive Care Unit, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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18
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Kompanje EJO, van Dijck JTJM, Chalos V, van den Berg SA, Janssen PM, Nederkoorn PJ, van der Jagt M, Citerio G, Stocchetti N, Dippel DWJ, Peul WC. Informed consent procedures for emergency interventional research in patients with traumatic brain injury and ischaemic stroke. Lancet Neurol 2020; 19:1033-1042. [PMID: 33098755 DOI: 10.1016/s1474-4422(20)30276-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022]
Abstract
Health-care professionals and researchers have a legal and ethical responsibility to inform patients before carrying out diagnostic tests or treatment interventions as part of a clinical study. Interventional research in emergency situations can involve patients with some degree of acute cognitive impairment, as is regularly the case in traumatic brain injury and ischaemic stroke. These patients or their proxies are often unable to provide informed consent within narrow therapeutic time windows. International regulations and national laws are criticised for being inconclusive or restrictive in providing solutions. Currently accepted consent alternatives are deferred consent, exception from consent, or waiver of consent. However, these alternatives appear under-utilised despite being ethically permissible, socially acceptable, and regulatorily compliant. We anticipate that, when the requirements for medical urgency are properly balanced with legal and ethical conduct, the increased use of these alternatives has the potential to improve the efficiency and quality of future emergency interventional studies in patients with an inability to provide informed consent.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Ethics and Philosophy of Medicine, Erasmus University, Rotterdam, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Vicky Chalos
- Department of Public Health, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Science, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Amsterdam UMC, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
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19
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Richards-Belle A, Davis P, Drikite L, Feltbower R, Grieve R, Harrison DA, Lester J, Morris KP, Mouncey PR, Peters MJ, Rowan KM, Sadique Z, Tume LN, Ramnarayan P. FIRST-line support for assistance in breathing in children (FIRST-ABC): a master protocol of two randomised trials to evaluate the non-inferiority of high-flow nasal cannula (HFNC) versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care. BMJ Open 2020; 10:e038002. [PMID: 32753452 PMCID: PMC7406113 DOI: 10.1136/bmjopen-2020-038002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/12/2020] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Even though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children. METHODS AND ANALYSIS We will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of extubation following a period of invasive ventilation (step-down RCT). Due to the emergency nature of the treatment, written informed consent will be deferred to after randomisation. Randomisation will occur 1:1 to CPAP or HFNC, stratified by site and age (<12 vs ≥12 months). The primary outcome is time to liberation from respiratory support for a continuous period of 48 hours. A total sample size of 600 patients in each RCT will provide 90% power with a type I error rate of 2.5% (one sided) to exclude the prespecified non-inferiority margin of HR of 0.75. Primary analyses will be undertaken separately in each RCT in both the intention-to-treat and per-protocol populations. ETHICS AND DISSEMINATION This master protocol received favourable ethical opinion from National Health Service East of England-Cambridge South Research Ethics Committee (reference: 19/EE/0185) and approval from the Health Research Authority (reference: 260536). Results will be disseminated via publications in peer-reviewed medical journals and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN60048867.
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Peter Davis
- Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital For Children NHS Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, Greater Manchester, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital For Children NHS Trust, London, UK
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20
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Chalos V, A van de Graaf R, Roozenbeek B, C G M van Es A, M den Hertog H, Staals J, van Dijk L, F M Jenniskens S, J van Oostenbrugge R, H van Zwam W, B W E M Roos Y, B L M Majoie C, F Lingsma H, van der Lugt A, W J Dippel D. Multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke. The effect of periprocedural medication: acetylsalicylic acid, unfractionated heparin, both, or neither (MR CLEAN-MED). Rationale and study design. Trials 2020; 21:644. [PMID: 32665035 PMCID: PMC7362523 DOI: 10.1186/s13063-020-04514-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite evidence of a quite large beneficial effect of endovascular treatment (EVT) for ischemic stroke caused by anterior circulation large vessel occlusion, many patients do not recover even after complete recanalization. To some extent, this may be attributable to incomplete microvascular reperfusion, which can possibly be improved by antiplatelet agents and heparin. It is unknown whether periprocedural antithrombotic medication in patients treated with EVT improves functional outcome. The aim of this study is to assess the effect of acetylsalicylic acid (ASA) and unfractionated heparin (UFH), alone, or in combination, given to patients with an ischemic stroke caused by an intracranial large vessel occlusion in the anterior circulation during EVT. METHODS MR CLEAN-MED is a multicenter phase III trial with a prospective, 2 × 3 factorial randomized, open label, blinded end-point (PROBE) design, which aims to enroll 1500 patients. The trial is designed to evaluate the effect of intravenous ASA (300 mg), UFH (low or moderate dose), both or neither as adjunctive therapy to EVT. We enroll adult patients with a clinical diagnosis of stroke (NIHSS ≥ 2) and with a confirmed intracranial large vessel occlusion in the anterior circulation on CTA or MRA, when EVT within 6 h from symptom onset is indicated and possible. The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days. Treatment effect on the mRS will be estimated with ordinal logistic regression analysis, with adjustment for main prognostic variables. Secondary outcomes include stroke severity measured with the NIHSS at 24 h and at 5-7 days, follow-up infarct volume, symptomatic intracranial hemorrhage (sICH), and mortality. DISCUSSION Clinical equipoise exists whether antithrombotic medication should be administered during EVT for a large vessel occlusion, as ASA and/or UFH may improve functional outcome, but might also lead to an increased risk of sICH. When one or both of the study treatments show the anticipated effect on outcome, we will be able to improve outcome of patients treated with EVT by 5%. This amounts to more than 50 patients annually in the Netherlands, more than 1800 in Europe, and more than 1300 in the USA. TRIAL REGISTRATION ISRCT, ISRCTN76741621 . Dec 6, 2017.
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Affiliation(s)
- Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Adriaan C G M van Es
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lukas van Dijk
- Department of Radiology & Nuclear Medicine, HagaZiekenhuis, Radiology, Den Haag, The Netherlands
| | - Sjoerd F M Jenniskens
- Department of Radiology & Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology & Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, University of Amsterdam, location AMC, Amsterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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21
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Hanrahan V, Gillies K, Biesty L. Recruiters' perspectives of recruiting women during pregnancy and childbirth to clinical trials: A qualitative evidence synthesis. PLoS One 2020; 15:e0234783. [PMID: 32559236 PMCID: PMC7304625 DOI: 10.1371/journal.pone.0234783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/02/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Research on research is key to enhancing efficacy in trial methodology. Clinical trials involving women during pregnancy and childbirth are limited, with a paucity of data guiding evidence-based practice. Following a prioritisation exercise that highlighted the top-ten unanswered recruitment questions, this qualitative evidence synthesis was designed specifically to focus on the barriers and enablers for clinicians/healthcare professionals in helping conduct randomised trials within the context of recruitment during pregnancy and childbirth. METHODS The synthesis was undertaken using Thomas and Harden's three stage thematic synthesis method and reported following the ENTREQ guidelines. Using a pre-determined SPIDER strategy, we conducted a comprehensive search of databases; Pubmed, CINAHL, PsycINFO, EMBASE, and grey searches for records until January 2019. We included all reports of qualitative data on recruiter's experiences, perceptions, views of recruiting women during pregnancy and childbirth to clinical trials. Altogether 13,401 records were screened, resulting in 31 full-text reviews, of which five were eligible for inclusion. Quality was appraised using CASP. Data were extracted onto a specifically defined form. We used thematic synthesis to identify descriptive and analytical themes, and to interpret and generate theory. Confidence was assessed using GRADE-CERQual. The review protocol is publicly available (OSF https://osf.io/g4dt9/). RESULTS Five papers (representing four individual studies) from two different countries were included. All studies focused on the experiences of trial recruiters in the maternity setting. We identified four analytical themes; Recruitment through a clinician's lens, Recruiters judgement on acceptability, From protocol to recruiters lived experience, Framing recruitment in context. These were linked by an overarching theme combining beliefs and power. CONCLUSION The overarching theme combining beliefs and power links the experiences and perceptions of recruiters. This synthesis shows a gap between the trial design study protocol and the recruiter's lived experience. Strategies such as collaborative trial design, mitigating gatekeeping behaviours, and training may support recruiters in their endeavour.
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Affiliation(s)
- Vivienne Hanrahan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Linda Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
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22
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Peters MJ, Khan I, Woolfall K, Deja E, Mouncey PR, Wulff J, Mason A, Agbeko R, Draper ES, Fenn B, Gould DW, Koelewyn A, Klein N, Mackerness C, Martin S, O'Neill L, Ramnarayan P, Tibby S, Tume L, Watkins J, Thorburn K, Wellman P, Harrison DA, Rowan KM. Different temperature thresholds for antipyretic intervention in critically ill children with fever due to infection: the FEVER feasibility RCT. Health Technol Assess 2020; 23:1-148. [PMID: 30793698 DOI: 10.3310/hta23050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fever accelerates host immune system control of pathogens but at a high metabolic cost. The optimal approach to fever management and the optimal temperature thresholds used for treatment in critically ill children are unknown. OBJECTIVES To determine the feasibility of conducting a definitive randomised controlled trial (RCT) to evaluate the clinical effectiveness and cost-effectiveness of different temperature thresholds for antipyretic management. DESIGN A mixed-methods feasibility study comprising three linked studies - (1) a qualitative study exploring parent and clinician views, (2) an observational study of the epidemiology of fever in children with infection in paediatric intensive care units (PICUs) and (3) a pilot RCT with an integrated-perspectives study. SETTING Participants were recruited from (1) four hospitals in England via social media (for the FEVER qualitative study), (2) 22 PICUs in the UK (for the FEVER observational study) and (3) four PICUs in England (for the FEVER pilot RCT). PARTICIPANTS (1) Parents of children with relevant experience were recruited to the FEVER qualitative study, (2) patients who were unplanned admissions to PICUs were recruited to the FEVER observational study and (3) children admitted with infection requiring mechanical ventilation were recruited to the FEVER pilot RCT. Parents of children and clinicians involved in the pilot RCT. INTERVENTIONS The FEVER qualitative study and the FEVER observational study had no interventions. In the FEVER pilot RCT, children were randomly allocated (1 : 1) using research without prior consent (RWPC) to permissive (39.5 °C) or restrictive (37.5 °C) temperature thresholds for antipyretics during their PICU stay while mechanically ventilated. MAIN OUTCOME MEASURES (1) The acceptability of FEVER, RWPC and potential outcomes (in the FEVER qualitative study), (2) the size of the potentially eligible population and the temperature thresholds used (in the FEVER observational study) and (3) recruitment and retention rates, protocol adherence and separation between groups and distribution of potential outcomes (in the FEVER pilot RCT). RESULTS In the FEVER qualitative study, 25 parents were interviewed and 56 clinicians took part in focus groups. Both the parents and the clinicians found the study acceptable. Clinicians raised concerns regarding temperature thresholds and not using paracetamol for pain/discomfort. In the FEVER observational study, 1853 children with unplanned admissions and infection were admitted to 22 PICUs between March and August 2017. The recruitment rate was 10.9 per site per month. The majority of critically ill children with a maximum temperature of > 37.5 °C received antipyretics. In the FEVER pilot RCT, 100 eligible patients were randomised between September and December 2017 at a recruitment rate of 11.1 per site per month. Consent was provided for 49 out of 51 participants in the restrictive temperature group, but only for 38 out of 49 participants in the permissive temperature group. A separation of 0.5 °C (95% confidence interval 0.2 °C to 0.8 °C) between groups was achieved. A high completeness of outcome measures was achieved. Sixty parents of 57 children took part in interviews and/or completed questionnaires and 98 clinicians took part in focus groups or completed a survey. Parents and clinicians found the pilot RCT and RWPC acceptable. Concerns about children being in pain/discomfort were cited as reasons for withdrawal and non-consent by parents and non-adherence to the protocol by clinicians. LIMITATIONS Different recruitment periods for observational and pilot studies may not fully reflect the population that is eligible for a definitive RCT. CONCLUSIONS The results identified barriers to delivering the definitive FEVER RCT, including acceptability of the permissive temperature threshold. The findings also provided insight into how these barriers may be overcome, such as by limiting the patient inclusion criteria to invasive ventilation only and by improved site training. A definitive FEVER RCT using a modified protocol should be conducted, but further work is required to agree important outcome measures for clinical trials among critically ill children. TRIAL REGISTRATION The FEVER observational study is registered as NCT03028818 and the FEVER pilot RCT is registered as Current Controlled Trials ISRCTN16022198. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Mark J Peters
- Respiratory, Critical Care and Anaesthesia Unit, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Imran Khan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Elizabeth Deja
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Jerome Wulff
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Alexina Mason
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Rachel Agbeko
- Paediatric Intensive Care Unit, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Abby Koelewyn
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nigel Klein
- Institute of Child Health, University College London, London, UK
| | - Christine Mackerness
- Paediatric Intensive Care Unit, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sian Martin
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Lauran O'Neill
- Respiratory, Critical Care and Anaesthesia Unit, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Shane Tibby
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lyvonne Tume
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | | | - Kent Thorburn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Paul Wellman
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
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23
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Abstract
OBJECTIVES To describe legal guardians' understanding of key concepts in a research consent form presented within 24 hours of their child's admission to the PICU and to explore legal guardians' opinions of the format (language, length) of the consent form and the overall consent process. DESIGN Single-center, exploratory pilot study. SETTING PICU at a tertiary-care hospital in Canada. SUBJECTS Forty-one English- and French-speaking legal guardians of children less than 18 years old, who had been admitted to the PICU within the past 24 hours and were expected to stay at least 48 hours, between October 2018 and February 2019. INTERVENTIONS The consent form from a previous PICU trial was given and explained to legal guardians within 24 hours of their child's admission to the PICU. MEASUREMENTS AND MAIN RESULTS Legal guardians' understanding of key concepts in the consent form was evaluated using a questionnaire the day after the form was explained, and opinions were collected verbally and using an additional survey. The median number of questions answered incorrectly was three of seven (interquartile range = 2-4). Participants best understood the topic of the study (5% incorrect), but 80% of participants were unable to recall a single risk. The median rating of the language in the form was five of five (very easy to understand; interquartile range = 4-5), and 88% of participants said it was a reasonable length. CONCLUSIONS Despite positive opinions of the consent form, most legal guardians did not understand all key components of the consent information provided to them orally and in writing within 24 hours of their child's PICU admission. Future studies are required to determine barriers to understanding and explore alternative approaches to obtaining consent in this setting.
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24
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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25
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Franklin D, Shellshear D, Babl FE, Schlapbach LJ, Oakley E, Borland ML, Hoeppner T, George S, Craig S, Neutze J, Williams A, Acworth J, McCay H, Wallace A, Mattes J, Gangathimn V, Wildman M, Fraser JF, Moloney S, Gavranich J, Waugh J, Hobbins S, Fahy R, Grew S, Gannon B, Gibbons K, Dalziel S, Schibler A. Multicentre, randomised trial to investigate early nasal high-flow therapy in paediatric acute hypoxaemic respiratory failure: a protocol for a randomised controlled trial-a Paediatric Acute respiratory Intervention Study (PARIS 2). BMJ Open 2019; 9:e030516. [PMID: 31857300 PMCID: PMC6937038 DOI: 10.1136/bmjopen-2019-030516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Acute hypoxaemic respiratory failure (AHRF) in children is the most frequent reason for non-elective hospital admission. During the initial phase, AHRF is a clinical syndrome defined for the purpose of this study by an oxygen requirement and caused by pneumonia, lower respiratory tract infections, asthma or bronchiolitis. Up to 20% of these children with AHRF can rapidly deteriorate requiring non-invasive or invasive ventilation. Nasal high-flow (NHF) therapy has been used by clinicians for oxygen therapy outside intensive care settings to prevent escalation of care. A recent randomised trial in infants with bronchiolitis has shown that NHF therapy reduces the need to escalate therapy. No similar data is available in the older children presenting with AHRF. In this study we aim to investigate in children aged 1 to 4 years presenting with AHRF if early NHF therapy compared with standard-oxygen therapy reduces hospital length of stay and if this is cost-effective compared with standard treatment. METHODS AND ANALYSIS The study design is an open-labelled randomised multicentre trial comparing early NHF and standard-oxygen therapy and will be stratified by sites and into obstructive and non-obstructive groups. Children aged 1 to 4 years (n=1512) presenting with AHRF to one of the participating emergency departments will be randomly allocated to NHF or standard-oxygen therapy once the eligibility criteria have been met (oxygen requirement with transcutaneous saturation <92%/90% (dependant on hospital standard threshold), diagnosis of AHRF, admission to hospital and tachypnoea ≥35 breaths/min). Children in the standard-oxygen group can receive rescue NHF therapy if escalation is required. The primary outcome is hospital length of stay. Secondary outcomes will include length of oxygen therapy, proportion of intensive care admissions, healthcare resource utilisation and associated costs. Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION Ethics approval has been obtained in Australia (HREC/15/QRCH/159) and New Zealand (HDEC 17/NTA/135). The trial commenced recruitment in December 2017. The study findings will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. Authorship of all publications will be decided by mutual consensus of the research team. TRIAL REGISTRATION NUMBER ACTRN12618000210279.
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Affiliation(s)
- Donna Franklin
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- School of Medicine, The University Of Queensland, St Lucia, Queensland, Australia
- Mater Medical Research Institute, South Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
| | - Deborah Shellshear
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Franz E Babl
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Services, University of Melbourne, Melbourne, Victoria, Australia
| | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- School of Medicine, The University Of Queensland, St Lucia, Queensland, Australia
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Ed Oakley
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Services, University of Melbourne, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia
- University of Western Australia, School of Medicine, Divisions of Emergency Medicine and Paediatrics, Crawley, Western Australia, Australia
| | - Tobias Hoeppner
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia
| | - Shane George
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- School of Medicine, The University Of Queensland, St Lucia, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Simon Craig
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Monash Medical Centre Clayton, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Science, Monash University, Clayton, Victoria, Australia
| | - Jocelyn Neutze
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- KidzFirst Middlemore Emergency Department, Middlemore Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | - Amanda Williams
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jason Acworth
- School of Medicine, The University Of Queensland, St Lucia, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Hamish McCay
- Paediatrics, Waikato Hospital, Hamilton, New Zealand
| | - Alex Wallace
- Paediatrics, Waikato Hospital, Hamilton, New Zealand
| | - Joerg Mattes
- Paediatrics, John Hunter Children's Hospital, Hunter Region Mail Centre, New South Wales, Australia
- University of Newcastle, Priority Research Centre GrowUpWell, Callaghan, New South Wales, Australia
| | - Vinay Gangathimn
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Townsville General Hospital, Townsville, Queensland, Australia
| | - Mark Wildman
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Emergency Department, Townsville General Hospital, Townsville, Queensland, Australia
| | - John F Fraser
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Susan Moloney
- Paediatric Department, Gold Coast University Hospital, Southport, Queensland, Australia
| | - John Gavranich
- Paediatrics, Ipswich Hospital, Ipswich, Queensland, Australia
| | - John Waugh
- Paediatrics, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Sue Hobbins
- Paediatrics, Prince Charles Hospital, Chermside, Queensland, Australia
| | - Rose Fahy
- Paediatrics, Prince Charles Hospital, Chermside, Queensland, Australia
| | - Simon Grew
- Paediatrics, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Brenda Gannon
- The University of Queensland, Centre for Business and Economics of Health, St Lucia Qld, Queensland, Australia
| | - Kristen Gibbons
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Stuart Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- University of Auckland, Auckland, New Zealand
- Starship Children's Health, Emergency Department, Newmarket, New Zealand
- Department of Surgery and Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- School of Medicine, The University Of Queensland, St Lucia, Queensland, Australia
- Mater Medical Research Institute, South Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
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Armstrong S, Langlois A, Siriwardena N, Quinn T. Ethical considerations in prehospital ambulance based research: qualitative interview study of expert informants. BMC Med Ethics 2019; 20:88. [PMID: 31775727 PMCID: PMC6882313 DOI: 10.1186/s12910-019-0425-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/11/2019] [Indexed: 11/15/2022] Open
Abstract
Background Prehospital ambulance based research has unique ethical considerations due to urgency, time limitations and the locations involved. We sought to explore these issues through interviews with experts in this research field. Methods We undertook semi-structured interviews with expert informants, primarily based in the UK, seeking their views and experiences of ethics in ambulance based clinical research. Participants were questioned regarding their experiences of ambulance based research, their opinions on current regulations and guidelines, and views about their general ethical considerations. Participants were chosen because they were actively involved in, or in their expert capacity (e.g. law) expressed an interest in, ambulance based research. Results Fourteen participants were interviewed including principal investigators, researchers, ethicists and medical lawyers. Five major themes were identified: Capacity, Consent, Clinical Considerations, Consultation and Regulation. Questions regarding consent and capacity were foremost in the discussions as all participants highlighted these as areas for concern. The challenges and use of multiple consent models reflected the complexity of research in this environment. The clinical theme referred to the role of paramedics in research and how research involving ambulance services is increasingly informing improvements to patient care and outcomes and reducing the burden on hospital services. Most felt that, although current regulations were fit for purpose, more specific guidance on implementing these in the ambulance setting would be beneficial. This related closely to the theme of consultation, which examined the key role of ethics committees and other regulatory bodies, as well as public engagement. Conclusions By interviewing experts in research or ethics in this setting we were able to identify key concerns and highlight areas for future development such as improved guidance.
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Affiliation(s)
- Stephanie Armstrong
- School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS, UK.
| | - Adele Langlois
- School of Social and Political Science, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS, UK
| | - Niroshan Siriwardena
- Professor of Primary and Pre-hospital Healthcare, Community and Health Research Unit School of Health and Social Care, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Kingston University and St George's, University of London, 6th Floor, Hunter Wing Cranmer Terrace, London, SW17 0RE, UK
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Waterfield T, Lyttle MD, Shields M, Fairley D, Roland D, McKenna J, Woolfall K. Parents' and clinicians' views on conducting paediatric diagnostic test accuracy studies without prior informed consent: qualitative insight from the Petechiae in Children study (PiC). Arch Dis Child 2019; 104:979-983. [PMID: 31175126 DOI: 10.1136/archdischild-2019-317117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Petechiae in Children (PiC) study assesses the utility of presenting features and rapid diagnostic tests in the diagnosis of serious bacterial infection in feverish children with non-blanching rashes. An embedded qualitative study explored parents' and clinicians' views on the acceptability of the PiC study, including the use of research without prior consent (RWPC) in studies of diagnostic test accuracy. DESIGN Semistructured qualitative interviews. Analysis was thematic and broadly interpretive, informed by the constant comparative approach. PARTICIPANTS Fifteen parents were interviewed 55 (median) days since their child's hospital attendance (range 13-95). Five clinicians involved in recruitment, and consent were interviewed. RESULTS Parents and clinicians supported RWPC for the PiC study and future emergency paediatric diagnostic test accuracy studies as long as there is no harm to the child and emergency care is not delayed. Parents and clinicians made recommendations around the timing and conduct of a consent discussion, which were in line with RWPC guidance. Parents enrolled in the PiC study preferred a design that included consent discussions with the research team over the alternative of 'opt-out' consent only. CONCLUSIONS This embedded qualitative study demonstrates that RWPC is appropriate for use in paediatric emergency studies of diagnostic test accuracy and that the approach used in PiC was appropriate. Future diagnostic studies involving additional invasive procedures or an opt-out only approach to consent would benefit from exploring parent and clinician views on acceptability at the pretrial stage. TRIAL REGISTRATION NUMBER NCT03378258.
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Affiliation(s)
- Thomas Waterfield
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | - Michael Shields
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Derek Fairley
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Damian Roland
- SAPPHIRE Group, University of Leicester, Leicester, UK
| | - James McKenna
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Kerry Woolfall
- Institute of Population Health and Society, University of Liverpool, Liverpool, UK
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Whitty CJM. Building UK infrastructure for research that benefits infants, children and young people. Arch Dis Child 2019; 104:825-826. [PMID: 30021787 DOI: 10.1136/archdischild-2017-314334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/01/2018] [Accepted: 07/02/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Christopher J M Whitty
- Department of Health and Social Care, National Institute for Health Research, London, UK.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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Doig CJ, Page SA, McKee JL, Moore EE, Abu-Zidan FM, Carroll R, Marshall JC, Faris PD, Tolonen M, Catena F, Cocolini F, Sartelli M, Ansaloni L, Minor SF, Peirera BM, Diaz JJ, Kirkpatrick AW. Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis. World J Emerg Surg 2019; 14:39. [PMID: 31404221 PMCID: PMC6683332 DOI: 10.1186/s13017-019-0259-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study (https://clinicaltrials.gov/ct2/show/NCT03163095) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS. Main body Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity. Conclusions A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.
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Affiliation(s)
- Christopher J Doig
- 1Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.,2Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Stacey A Page
- 2Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jessica L McKee
- 3Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | | | - Fikri M Abu-Zidan
- 7Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, UAE
| | - Rosemary Carroll
- 8Surgical Services John Hunter Hospital, Newcastle, NSW Australia
| | - John C Marshall
- 6Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Peter D Faris
- 5Research Facilitation Analytics (DIMR), University of Calgary, Calgary, Alberta Canada
| | - Matti Tolonen
- 9Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Fausto Catena
- 10Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Cocolini
- 11General, Emergency and Trauma Surgery dept, Bufalini Hospital, Cesena, Italy
| | | | - Luca Ansaloni
- 13Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesena, Italy
| | - Sam F Minor
- 14Department of Critical Care and Department of Surgery, NSHA- Queen Elizabeth II Health Sciences Centre, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
| | - Bruno M Peirera
- 15Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Jose J Diaz
- 16Department of Surgery, Acute Care Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
| | - Andrew W Kirkpatrick
- 17Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,18Department of Surgery, University of Calgary, Calgary, Alberta Canada.,19EG23 Foothills Medical Centre, Calgary, Alberta T2N 2 T9 Canada
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Brown P, Hewison A, Newham R. What are research nurses' experiences of obtaining consent from or for patients participating in emergency care research? A qualitative review. J Clin Nurs 2019; 28:4155-4165. [PMID: 31241806 DOI: 10.1111/jocn.14984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/06/2019] [Accepted: 06/09/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION If studies are to be valid, recruitment of representative samples is essential. In 2012, 28% of UK emergency departments met the 80% standard for recruitment to trials set by the National Institute for Health Research. Research nurses play a vital role in the conduct of high-quality research, and it has been argued that dedicated research nurses are needed if clinical trials are to recruit successfully to target. REVIEW QUESTION What are research nurses' experiences of obtaining consent from or for patients participating in emergency care research? A qualitative evidence review. METHODS A qualitative integrative literature review with a narrative synthesis of the evidence. PRISMA guidelines for reporting systematic qualitative reviews (Appendix S1) were followed. A search of five electronic databases was performed in December 2018 along with a hand search which yielded 125 citations: 10 papers and one PhD thesis met the review eligibility criteria. Methodological quality of the selected studies was evaluated, and data were extracted and synthesised. RESULTS Three themes were identified: Access, Organisation and Timing. Research nurses encountered both general and specific barriers when seeking to obtain consent for participation in research. In particular, it was found there was lack of experience among staff of working in emergency research and with securing deferred consent. The distinction between nurse researchers with a clinical role and those dedicated to solely to research only is often not clear and warrants further investigation. CONCLUSION Nurse researchers with and without a clinical role can make a positive difference in recruitment to trials in emergency care. The involvement of dedicated research nurses in the consent process can increase recruitment to emergency care research. Experience of recruiting to clinical trials in nonemergency settings does not seem to help when recruiting for trials in emergency care. RELEVANCE TO CLINICAL PRACTICE There is a need for greater understanding of the experiences of dedicated research nurses in emergency care settings and in particular with regard to deferred consent.
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Affiliation(s)
| | - Alistair Hewison
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Roger Newham
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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George S, Humphreys S, Williams T, Gelbart B, Chavan A, Rasmussen K, Ganeshalingham A, Erickson S, Ganu SS, Singhal N, Foster K, Gannon B, Gibbons K, Schlapbach LJ, Festa M, Dalziel S, Schibler A. Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial. BMJ Open 2019; 9:e025997. [PMID: 30787094 PMCID: PMC6398737 DOI: 10.1136/bmjopen-2018-025997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care. METHODS AND ANALYSIS The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0-16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (<1, 1-7 and >7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO2 <90% (patient-dependent variable) and (2) first intubation attempt success without hypoxemia (operator-dependent variable). Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12617000147381.
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Affiliation(s)
- Shane George
- Children’s Critical Care Service, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University, Southport, Queensland, Australia
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
| | - Susan Humphreys
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Tara Williams
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, The Townsville Hospital, Townsville, Queensland, Australia
| | - Katie Rasmussen
- Critical Care Division, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- Paediatric Emergency Research Unit, Centre for Children’s Health Research, Children’s Health Queensland, Brisbane, Queensland, Australia
| | | | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Subodh Suhas Ganu
- Department of Paediatric Critical Care Medicine, Women’s and Children’s Hospital, North Adelaide, South Australia, Australia
| | - Nitesh Singhal
- Paediatric Intensive Care Unit, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
| | - Kelly Foster
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Paediatric Emergency Research Unit, Centre for Children’s Health Research, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Brenda Gannon
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Marino Festa
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
| | - Stuart Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Starship Children’s Hospital, Auckland, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Andreas Schibler
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
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Rich WD, Katheria AC. Waived Consent in Perinatal/Neonatal Research-When Is It Appropriate? Front Pediatr 2019; 7:493. [PMID: 31850290 PMCID: PMC6901905 DOI: 10.3389/fped.2019.00493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022] Open
Abstract
Informed consent is a process ensuring that subjects enrolled in research are appropriately informed of the risks and benefits. While this process is well-defined when it is possible and practical to obtain consent prior to the research intervention, it can be less clear in cases of deferred or waived consent. Defining minimal risk, such as when research is attempting to determine which of two currently practiced interventions is safest and/or most effective, is critical to moving forward in establishing appropriate care in newborns. For perinatal/neonatal research the challenge lies between the ethical justification for approaching women in labor or under medication vs. the scientific integrity of excluding a number of subjects that may potentially benefit the most from an intervention. Researchers must work with their IRBs as well as families who have participated in trials to determine the most appropriate method for obtaining informed consent from expectant parents. Clinical researchers and IRBs ultimately need to find a middle ground for the appropriate use of deferred or waived consent.
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Affiliation(s)
- Wade D Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
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Furyk J, McBain-Rigg K, Renison B, Watt K, Franklin R, Emeto TI, Ray RA, Babl FE, Dalziel S. A comprehensive systematic review of stakeholder attitudes to alternatives to prospective informed consent in paediatric acute care research. BMC Med Ethics 2018; 19:89. [PMID: 30453948 PMCID: PMC6245534 DOI: 10.1186/s12910-018-0327-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A challenge of performing research in the paediatric emergency and acute care setting is obtaining valid prospective informed consent from parents. The ethical issues are complex, and it is important to consider the perspective of participants, health care workers and researchers on research without prospective informed consent while planning this type of research. METHODS We performed a systematic review according to PRISMA guidelines, of empirical evidence relating to the process, experiences and acceptability of alternatives to prospective informed consent, in the paediatric emergency or acute care setting. Major medical databases and grey sources were searched and results were screened and assessed against eligibility criteria by 2 authors, and full text articles of relevant studies obtained. Data were extracted onto data collection forms and imported into data management software for analysis. RESULTS Thirteen studies were included in the review consisting of nine full text articles and four abstracts. Given the heterogeneity of the methods, results could not be quantitatively combined for meta-analysis, and qualitative results are presented in narrative form, according to themes identified from the data. Major themes include capacity of parents to provide informed consent, feasibility of informed consent, support for alternatives to informed consent, process issues, modified consent process, child death, and community consultation. CONCLUSION Our review demonstrated that children, their families, and health care staff recognise the requirement for research without prior consent, and are generally supportive of enrolling children in such research with the provisions of limiting risk, and informing parents as soon as possible. Australian data and perspectives of children are lacking and represent important knowledge gaps.
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Affiliation(s)
- Jeremy Furyk
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4814 Australia
- University Hospital Geelong, Geelong, Victoria Australia
| | - Kris McBain-Rigg
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4814 Australia
| | - Bronia Renison
- Townsville Health Library, Townsville Hospital and Health Service, James Cook University, Townsville, QLD Australia
| | - Kerrianne Watt
- Research Methods & Injury Epidemiology, College of Public Health, Medical and Veterinary Science, James Cook University, QLD, Townsville, 4811 Australia
| | - Richard Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4814 Australia
| | - Theophilus I. Emeto
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4814 Australia
| | - Robin A. Ray
- College Medicine and Dentistry, James Cook University, Townsville, QLD Australia
| | - Franz E. Babl
- Emergency Department, Royal Children’s Hospital, Melbourne, 50 Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Melbourne, 50 Flemington Rd, Parkville, VIC 3052 Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, VIC 3010 Australia
| | - Stuart Dalziel
- Emergency Medicine Research, Children’s Emergency Department, Starship Children’s Hospital, Auckland District Health Board, Private Bag 92024, Auckland, 1142 New Zealand
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Feinstein Y, Walker JC, Peters MJ, Nadel S, Pathan N, Edmonds N, Herberg J, Kaforou M, Wright V, Levin M, Ramnarayan P. Cohort profile of the Biomarkers of Acute Serious Illness in Children (BASIC) study: a prospective multicentre cohort study in critically ill children. BMJ Open 2018; 8:e024729. [PMID: 30413517 PMCID: PMC6231583 DOI: 10.1136/bmjopen-2018-024729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/03/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Despite significant progress, challenges remain in the management of critically ill children, including early identification of infection and organ failure and robust early risk stratification to predict poor outcome. The Biomarkers of Acute Serious Illness in Children study aims to identify genetic and biological pathways underlying the development of critical illness in infections and organ failure and those leading to poor outcome (death or severe disability) in children requiring emergency intensive care. PARTICIPANTS We recruited a prospective cohort of critically ill children undergoing emergency transport to four paediatric intensive care units (PICUs) in Southeast England between April 2014 and December 2016. FINDINGS TO DATE During the study period, 1017 patients were recruited by the regional PICU transport team, and blood and urine samples were obtained at/around first contact with the patient by the transport team. Consent for participation in the study was deferred until after PICU admission and 674 parents/carers were consented. Further samples (blood, urine, stool and throat swabs) were collected after consent. Samples were processed and stored for genomic, transcriptomic, proteomic and metabolomic analyses. Demographic, clinical and laboratory data at first contact, during PICU stay and at discharge, were collected, as were detailed data regarding infectious or non-infectious aetiology. In addition, 115 families have completed 12-month validated follow-up questionnaires to assess quality of life and child behaviour.The first phase of sample analyses (transcriptomic profiling) is currently in progress. FUTURE PLANS Stored samples will be analysed using genomic, proteomic and metabolic profiling. Advanced bioinformatics techniques will be used to identify biomarkers for early diagnosis of infection, identification of organ failure and risk stratification to predict poor outcome (death/severe disability). TRIAL REGISTRATION NUMBER NCT03238040.
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Affiliation(s)
- Yael Feinstein
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Paediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jennifer Claire Walker
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nazima Pathan
- Paediatrics Intensive Care, Addenbrookes’ Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Naomi Edmonds
- Paediatric Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Jethro Herberg
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Myrsini Kaforou
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Victoria Wright
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Michael Levin
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Padmanabhan Ramnarayan
- Paediatric Intensive Care, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Ramnarayan P, Lister P, Dominguez T, Habibi P, Edmonds N, Canter RR, Wulff J, Harrison DA, Mouncey PM, Peters MJ. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Crit Care 2018; 22:144. [PMID: 29866165 PMCID: PMC5987627 DOI: 10.1186/s13054-018-2080-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care. METHODS In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT. RESULTS Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2). CONCLUSIONS Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients. TRIAL REGISTRATION clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Children's Acute Transport Service, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, 26-27 Boswell Street, London, WC1N 3JZ, UK. .,Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Paula Lister
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Troy Dominguez
- Cardiac Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Parviz Habibi
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Naomi Edmonds
- Paediatric Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Jerome Wulff
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Paul M Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Mark J Peters
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Respiratory, Critical Care and Anaesthesia Unit, Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Furyk J, Franklin R, Watt K, Emeto T, Dalziel S, McBain-Rigg K, Stepanov N, Babl FE. Community attitudes to emergency research without prospective informed consent: A survey of the general population. Emerg Med Australas 2018; 30:547-555. [DOI: 10.1111/1742-6723.12958] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/08/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Jeremy Furyk
- Emergency Department; The Townsville Hospital; Townsville Queensland Australia
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
- Public Health and Tropical Medicine; James Cook University; Brisbane Queensland Australia
| | - Richard Franklin
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Kerrianne Watt
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Theopilus Emeto
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Stuart Dalziel
- Children's Emergency Department; Starship Children's Hospital; Auckland New Zealand
| | - Kris McBain-Rigg
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Nikola Stepanov
- Emergency Department; The Townsville Hospital; Townsville Queensland Australia
| | - Franz E Babl
- Emergency Department; Royal Children's Hospital; Melbourne Victoria Australia
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Songstad NT, Roberts CT, Manley BJ, Owen LS, Davis PG. Retrospective Consent in a Neonatal Randomized Controlled Trial. Pediatrics 2018; 141:peds.2017-2092. [PMID: 29288162 DOI: 10.1542/peds.2017-2092] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The requirement for prospective consent in clinical trials in acute settings may result in samples unrepresentative of the study population, potentially altering study findings. However, using retrospective consent may raise ethical issues. We assessed whether using retrospective consent affected recruitment, participant characteristics, and outcomes within a randomized controlled trial. METHODS We conducted a secondary analysis of a randomized trial, which compared nasal high flow (nHF) with nasal continuous positive airway pressure (CPAP) for primary respiratory support in preterm infants. In Era 1, all infants were consented prospectively; in Era 2, retrospective consent was available. We assessed inclusion rates of eligible infants, demographic data, and primary trial outcome (treatment failure within 72 hours). RESULTS In Era 1, recruitment of eligible infants was lower than in Era 2: 111 of 220 (50%) versus 171 of 209 (82%), P < .001; intrapartum antibiotic administration was lower: 23 of 111 (21%) versus 84 of 165 (51%), P < .001; full courses of antenatal steroids were higher: 86 of 111 (78%) versus 103 of 170 (61%), P = .004; and more infants received pre-randomization CPAP: 77 of 111 (69%) versus 48 of 171 (28%), P < .001. In Era 1, nHF failure (15 of 56, 27%) and CPAP failure (14 of 55, 26%) rates were similar, P = .9. In Era 2, failure rates differed: 24 of 85 (28%) nHF infants versus 13 of 86 (15%) CPAP infants, P = .04. The χ2 interaction test was nonsignificant (P = .20). CONCLUSIONS The use of retrospective consent resulted in greater recruitment and differences in risk factors between eras. Using retrospective consent altered the study sample, which may be more representative of the whole population. This may improve scientific validity but requires further ethical evaluation.
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Affiliation(s)
- Nils T Songstad
- Newborn Research Centre and .,Department of Pediatrics and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Calum T Roberts
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and
| | - Brett J Manley
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and
| | - Louise S Owen
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and.,Murdoch Children's Research Institute, Melbourne, Australia
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Furyk J, McBain-Rigg K, Watt K, Emeto TI, Franklin RC, Franklin D, Schibler A, Dalziel SR, Babl FE, Wilson C, Phillips N, Ray R. Qualitative evaluation of a deferred consent process in paediatric emergency research: a PREDICT study. BMJ Open 2017; 7:e018562. [PMID: 29146655 PMCID: PMC5695338 DOI: 10.1136/bmjopen-2017-018562] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A challenge of conducting research in critically ill children is that the therapeutic window for the intervention may be too short to seek informed consent prior to enrolment. In specific circumstances, most international ethical guidelines allow for children to be enrolled in research with informed consent obtained later, termed deferred consent (DC) or retrospective consent. There is a paucity of data on the attitudes of parents to this method of enrolment in paediatric emergency research. OBJECTIVES To explore the attitudes of parents to the concept of DC and to expand the knowledge of the limitations to informed consent and DC in these situations. METHOD Children presenting with uncomplicated febrile seizures or bronchiolitis were identified from three separate hospital emergency department databases. Parents were invited to participate in a semistructured telephone interview exploring themes of limitations of prospective informed consent, acceptability of the DC process and the most appropriate time to seek DC. Transcripts underwent inductive thematic analysis with intercoder agreement, using Nvivo 11 software. RESULTS A total of 39 interviews were conducted. Participants comprehended the limitations of informed consent under emergency circumstances and were generally supportive of DC. However, they frequently confused concepts of clinical care and research, and support for participation was commonly linked to their belief of personal benefit. CONCLUSION Participants acknowledged the requirement for alternatives to prospective informed consent in emergency research, and were supportive of the concept of DC. Our results suggest that current research practice seems to align with community expectations.
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Affiliation(s)
- Jeremy Furyk
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Kristin McBain-Rigg
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Kerrianne Watt
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Theophilus I Emeto
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Richard C Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Donna Franklin
- Paediatric Critical Care Research Group, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia
- Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia
- Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Stuart R Dalziel
- Starship Children’s Hospital, Auckland, New Zealand
- The University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
| | - Catherine Wilson
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia
| | - Robin Ray
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Ramnarayan P, Lister P, Dominguez T, Habibi P, Edmonds N, Canter R, Mouncey P, Peters MJ. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children. BMJ Open 2017; 7:e016181. [PMID: 28606907 PMCID: PMC5541500 DOI: 10.1136/bmjopen-2017-016181] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Over 18 000 children are admitted annually to UK paediatric intensive care units (PICUs), of whom nearly 75% receive respiratory support (invasive and/or non-invasive). Continuous positive airway pressure (CPAP) has traditionally been used to provide first-line non-invasive respiratory support (NRS) in PICUs; however, high-flow nasal cannula therapy (HFNC), a novel mode of NRS, has recently gained popularity despite the lack of high-quality trial evidence to support its effectiveness. This feasibility study aims to inform the design and conduct of a future definitive randomised clinical trial (RCT) comparing the two modes of respiratory support. METHODS AND ANALYSIS We will conduct a three-centre randomised feasibility study over 12 months. Patients admitted to participating PICUs who satisfy eligibility criteria will be recruited to either group A (primary respiratory failure) or group B (postextubation). Consent will be obtained from parents/guardians prior to randomisation in 'planned' group B, and deferred in emergency situations (group A and 'rescue' group B). Participants will be randomised (1:1) to either CPAP or HFNC using sealed, opaque envelopes, from a computer-generated randomisation sequence with variable block sizes. The study protocol specifies algorithms for the initiation, maintenance and weaning of HFNC and CPAP. The primary outcomes are related to feasibility, including the number of eligible patients in each group, feasibility of randomising >50% of eligible patients and measures of adherence to the treatment protocols. Data will also be collected on patient outcomes (eg, mortality and length of PICU stay) to inform the selection of an appropriate outcome measure in a future RCT. We aim to recruit 120 patients to the study. ETHICS AND DISSEMINATION Ethical approval was granted by the National Research Ethics Service Committee North East-Tyne&Wear South (15/NE/0296). Study findings will be disseminated through peer-reviewed journals, national and international conferences. TRIALS REGISTRATION NUMBER NCT02612415; pre-results.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Children’s Acute Transport Service, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Paula Lister
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Troy Dominguez
- Cardiac Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Parviz Habibi
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Naomi Edmonds
- Paediatric Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ruth Canter
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Mark J Peters
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Respiratory, Critical Care and Anaesthesia Section, Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Harron K, Mok Q, Dwan K, Ridyard CH, Moitt T, Millar M, Ramnarayan P, Tibby SM, Muller-Pebody B, Hughes DA, Gamble C, Gilbert RE. CATheter Infections in CHildren (CATCH): a randomised controlled trial and economic evaluation comparing impregnated and standard central venous catheters in children. Health Technol Assess 2016; 20:vii-xxviii, 1-219. [PMID: 26935961 DOI: 10.3310/hta20180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Impregnated central venous catheters (CVCs) are recommended for adults to reduce bloodstream infection (BSI) but not for children. OBJECTIVE To determine the effectiveness of impregnated compared with standard CVCs for reducing BSI in children admitted for intensive care. DESIGN Multicentre randomised controlled trial, cost-effectiveness analysis from a NHS perspective and a generalisability analysis and cost impact analysis. SETTING 14 English paediatric intensive care units (PICUs) in England. PARTICIPANTS Children aged < 16 years admitted to a PICU and expected to require a CVC for ≥ 3 days. INTERVENTIONS Heparin-bonded, antibiotic-impregnated (rifampicin and minocycline) or standard polyurethane CVCs, allocated randomly (1 : 1 : 1). The intervention was blinded to all but inserting clinicians. MAIN OUTCOME MEASURE Time to first BSI sampled between 48 hours after randomisation and 48 hours after CVC removal. The following data were used in the trial: trial case report forms; hospital administrative data for 6 months pre and post randomisation; and national-linked PICU audit and laboratory data. RESULTS In total, 1859 children were randomised, of whom 501 were randomised prospectively and 1358 were randomised as an emergency; of these, 984 subsequently provided deferred consent for follow-up. Clinical effectiveness - BSIs occurred in 3.59% (18/502) of children randomised to standard CVCs, 1.44% (7/486) of children randomised to antibiotic CVCs and 3.42% (17/497) of children randomised to heparin CVCs. Primary analyses comparing impregnated (antibiotic and heparin CVCs) with standard CVCs showed no effect of impregnated CVCs [hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.37 to 1.34]. Secondary analyses showed that antibiotic CVCs were superior to standard CVCs (HR 0.43, 95% CI 0.20 to 0.96) but heparin CVCs were not (HR 1.04, 95% CI 0.53 to 2.03). Time to thrombosis, mortality by 30 days and minocycline/rifampicin resistance did not differ by CVC. Cost-effectiveness - heparin CVCs were not clinically effective and therefore were not cost-effective. The incremental cost of antibiotic CVCs compared with standard CVCs over a 6-month time horizon was £1160 (95% CI -£4743 to £6962), with an incremental cost-effectiveness ratio of £54,057 per BSI avoided. There was considerable uncertainty in costs: antibiotic CVCs had a probability of 0.35 of being dominant. Based on index hospital stay costs only, antibiotic CVCs were associated with a saving of £97,543 per BSI averted. The estimated value of health-care resources associated with each BSI was £10,975 (95% CI -£2801 to £24,751). Generalisability and cost-impact - the baseline risk of BSI in 2012 for PICUs in England was 4.58 (95% CI 4.42 to 4.74) per 1000 bed-days. An estimated 232 BSIs could have been averted in 2012 using antibiotic CVCs. The additional cost of purchasing antibiotic CVCs for all children who require them (£36 per CVC) would be less than the value of resources associated with managing BSIs in PICUs with standard BSI rates of > 1.2 per 1000 CVC-days. CONCLUSIONS The primary outcome did not differ between impregnated and standard CVCs. However, antibiotic-impregnated CVCs significantly reduced the risk of BSI compared with standard and heparin CVCs. Adoption of antibiotic-impregnated CVCs could be beneficial even for PICUs with low BSI rates, although uncertainty remains whether or not they represent value for money to the NHS. Limitations - inserting clinicians were not blinded to allocation and a lower than expected event rate meant that there was limited power for head-to-head comparisons of each type of impregnation. Future work - adoption of impregnated CVCs in PICUs should be considered and could be monitored through linkage of electronic health-care data and clinical data on CVC use with laboratory surveillance data on BSI. TRIAL REGISTRATION ClinicalTrials.gov NCT01029717. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katie Harron
- Institute of Child Health, University College London, London, UK
| | - Quen Mok
- Great Ormond Street Hospital, London, UK
| | - Kerry Dwan
- Medicines for Children Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Colin H Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Tracy Moitt
- Medicines for Children Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | | | | | | | - Berit Muller-Pebody
- Healthcare Associated Infection and Antimicrobial Resistance (HCAI & AMR) Department, National Infection Service, Public Health England, London, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Carrol Gamble
- Medicines for Children Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Ruth E Gilbert
- Institute of Child Health, University College London, London, UK
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Gilbert RE, Mok Q, Dwan K, Harron K, Moitt T, Millar M, Ramnarayan P, Tibby SM, Hughes D, Gamble C. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): a randomised controlled trial. Lancet 2016; 387:1732-42. [PMID: 26946925 DOI: 10.1016/s0140-6736(16)00340-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Impregnated central venous catheters are recommended for adults to reduce bloodstream infections but not for children because there is not enough evidence to prove they are effective. We aimed to assess the effectiveness of any type of impregnation (antibiotic or heparin) compared with standard central venous catheters to prevent bloodstream infections in children needing intensive care. METHODS We did a randomised controlled trial of children admitted to 14 English paediatric intensive care units. Children younger than 16 years were eligible if they were admitted or being prepared for admission to a participating paediatric intensive care unit and were expected to need a central venous catheter for 3 or more days. Children were randomly assigned (1:1:1) to receive a central venous catheter impregnated with antibiotics, a central venous catheter impregnated with heparin, or a standard central venous catheter with computer generated randomisation in blocks of three and six, stratified by method of consent, site, and envelope storage location within the site. The clinician responsible for inserting the central venous catheter was not masked to allocation, but allocation was concealed from patients, their parents, and the paediatric intensive care unit personnel responsible for their care. The primary outcome was time to first bloodstream infection between 48 h after randomisation and 48 h after central venous catheter removal with impregnated (antibiotic or heparin) versus standard central venous catheters, assessed in the intention-to-treat population. Safety analyses compared central venous catheter-related adverse events in the subset of children for whom central venous catheter insertion was attempted (per-protocol population). This trial is registered with ISRCTN number, ISRCTN34884569. FINDINGS Between Nov 25, 2010, and Nov 30, 2012, 1485 children were recruited to this study. We randomly assigned 502 children to receive standard central venous catheters, 486 to receive antibiotic-impregnated catheters, and 497 to receive heparin-impregnated catheters. Bloodstream infection occurred in 18 (4%) of those in the standard catheters group, 7 (1%) in the antibiotic-impregnated group, and 17 (3%) assigned to heparin-impregnated catheters. Primary analyses showed no effect of impregnated (antibiotic or heparin) catheters compared with standard central venous catheters (hazard ratio [HR] for time to first bloodstream infection 0.71, 95% CI 0.37-1.34). Secondary analyses showed that antibiotic central venous catheters were better than standard central venous catheters (HR 0.43, 0.20-0.96) and heparin central venous catheters (HR 0.42, 0.19-0.93), but heparin did not differ from standard central venous catheters (HR 1.04, 0.53-2.03). Clinically important and statistically significant absolute risk differences were identified only for antibiotic-impregnated catheters versus standard catheters (-2.15%, 95% CI -4.09 to -0.20; number needed to treat [NNT] 47, 95% CI 25-500) and antibiotic-impregnated catheters versus heparin-impregnated catheters (-1.98%, -3.90 to -0.06, NNT 51, 26-1667). Nine children (2%) in the standard central venous catheter group, 14 (3%) in the antibiotic-impregnated group, and 8 (2%) in the heparin-impregnated group had catheter-related adverse events. 45 (8%) in the standard group, 35 (8%) antibiotic-impregnated group, and 29 (6%) in the heparin-impregnated group died during the study. INTERPRETATION Antibiotic-impregnated central venous catheters significantly reduced the risk of bloodstream infections compared with standard and heparin central venous catheters. Widespread use of antibiotic-impregnated central venous catheters could help prevent bloodstream infections in paediatric intensive care units. FUNDING National Institute for Health Research, UK.
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Affiliation(s)
| | - Quen Mok
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Kerry Dwan
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | | | - Tracy Moitt
- Medicines for Children Clinical Trials Unit University, University of Liverpool, Liverpool, UK
| | - Mike Millar
- Department of Infection, Barts Health NHS Trust, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children, London, UK
| | - Shane M Tibby
- Evelina Children's Hospital, St Thomas's Hospital, London, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, Wales
| | - Carrol Gamble
- Department of Biostatistics, University of Liverpool, Liverpool, UK
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Affiliation(s)
- Adrienne G Randolph
- Critical Care Division, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA 02115, USA; Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA, USA.
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Opportunities for Enhancing Patient Recruitment in Clinical Research: Building an Evidence Base for Critical Care Medicine. Pediatr Crit Care Med 2016; 17:267-9. [PMID: 26945203 DOI: 10.1097/pcc.0000000000000651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Woolfall K, Frith L, Gamble C, Gilbert R, Mok Q, Young B. How parents and practitioners experience research without prior consent (deferred consent) for emergency research involving children with life threatening conditions: a mixed method study. BMJ Open 2015; 5:e008522. [PMID: 26384724 PMCID: PMC4577875 DOI: 10.1136/bmjopen-2015-008522] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Alternatives to prospective informed consent to enable children with life-threatening conditions to be entered into trials of emergency treatments are needed. Across Europe, a process called deferred consent has been developed as an alternative. Little is known about the views and experiences of those with first-hand experience of this controversial consent process. To inform how consent is sought for future paediatric critical care trials, we explored the views and experiences of parents and practitioners involved in the CATheter infections in CHildren (CATCH) trial, which allowed for deferred consent in certain circumstances. DESIGN Mixed method survey, interview and focus group study. PARTICIPANTS 275 parents completed a questionnaire; 20 families participated in an interview (18 mothers, 5 fathers). 17 CATCH practitioners participated in one of four focus groups (10 nurses, 3 doctors and 4 clinical trial unit staff). SETTING 12 UK children's hospitals. RESULTS Some parents were momentarily shocked or angered to discover that their child had or could have been entered into CATCH without their prior consent. Although these feelings resolved after the reasons why consent needed to be deferred were explained and that the CATCH interventions were already used in clinical care. Prior to seeking deferred consent for the first few times, CATCH practitioners were apprehensive, although their feelings abated with experience of talking to parents about CATCH. Parents reported that their decisions about their child's participation in the trial had been voluntary. However, mistiming the deferred consent discussion had caused distress for some. Practitioners and parents supported the use of deferred consent in CATCH and in future trials of interventions already used in clinical care. CONCLUSIONS Our study provides evidence to support the use of deferred consent in paediatric emergency medicine; it also indicates the crucial importance of practitioner communication and appropriate timing of deferred consent discussions.
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Affiliation(s)
- Kerry Woolfall
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Lucy Frith
- Department of Health Service Research, University of Liverpool, Liverpool, UK
| | - Carrol Gamble
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | | | - Quen Mok
- Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, London, UK
| | - Bridget Young
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
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