1
|
Tokita HK, Assel M, Serafin J, Lin E, Sarraf L, Masson G, Moo TA, Nelson JA, Simon BA, Vickers AJ. Optimizing accrual to a large-scale, clinically integrated randomized trial in anesthesiology: A 2-year analysis of recruitment. Clin Trials 2024:17407745241255087. [PMID: 38895970 DOI: 10.1177/17407745241255087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time. METHODS This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions. RESULTS Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%-9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%-6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%. CONCLUSION The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology.
Collapse
Affiliation(s)
- Hanae K Tokita
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanna Serafin
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily Lin
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leslie Sarraf
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geema Masson
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brett A Simon
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
2
|
Pasli M, Tumin D, Guffey R. Simulation-Based Analysis of Trial Design in Regional Anesthesia. Anesthesiol Res Pract 2024; 2024:6651894. [PMID: 38525205 PMCID: PMC10959581 DOI: 10.1155/2024/6651894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/01/2023] [Accepted: 02/12/2024] [Indexed: 03/26/2024] Open
Abstract
Background In regional anesthesia, the efficacy of novel blocks is typically evaluated using randomized controlled trials (RCTs), the findings of which are aggregated in systematic reviews and meta-analyses. Systematic review authors frequently point out the small sample size of RCTs as limiting conclusions from this literature. We sought to determine via statistical simulation if small sample size could be an expected property of RCTs focusing on novel blocks with typical effect sizes. Methods We simulated the conduct of a series of RCTs comparing a novel block versus placebo on a single continuous outcome measure. Simulation analysis inputs were obtained from a systematic bibliographic search of meta-analyses. Primary outcomes were the predicted number of large trials (empirically defined as N ≥ 256) and total patient enrollment. Results Simulation analysis predicted that a novel block would be tested in 16 RCTs enrolling a median of 970 patients (interquartile range (IQR) across 1000 simulations: 806, 1269), with no large trials. Among possible modifications to trial design, decreasing the statistical significance threshold from p < 0.05 to p < 0.005 was most effective at increasing the total number of patients represented in the final meta-analysis, but was associated with early termination of the trial sequence due to futility in block vs. block comparisons. Conclusion Small sample size of regional anesthesia RCTs comparing novel block to placebo is a rational outcome of trial design. Feasibly large trials are unlikely to change conclusions regarding block vs. placebo comparisons.
Collapse
Affiliation(s)
- Melisa Pasli
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
- Department of Academic Affairs, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ryan Guffey
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| |
Collapse
|
3
|
Yanes JA, McKinnell ZE, Reid MA, Busler JN, Michel JS, Pangelinan MM, Sutherland MT, Younger JW, Gonzalez R, Robinson JL. Effects of cannabinoid administration for pain: A meta-analysis and meta-regression. Exp Clin Psychopharmacol 2019; 27:370-382. [PMID: 31120281 PMCID: PMC6663642 DOI: 10.1037/pha0000281] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic pain states have resulted in an overreliance on opioid pain relievers, which can carry significant risks when used long term. As such, alternative pain treatments are increasingly desired. Although emerging research suggests that cannabinoids have therapeutic potential regarding pain, results from studies across pain populations have been inconsistent. To provide meta-analytic clarification regarding cannabis's impact on subjective pain, we identified studies that assessed drug-induced pain modulations under cannabinoid and corresponding placebo conditions. A literature search yielded 25 peer-reviewed records that underwent data extraction. Baseline and end-point data were used to compute standardized effect size estimates (Cohen's d) across cannabinoid administrations (k = 39) and placebo administrations (k = 26). Standardized effects were inverse-variance weighted and pooled across studies for meta-analytic comparison. Results revealed that cannabinoid administration produced a medium-to-large effect across included studies, Cohen's d = -0.58, 95% confidence interval (CI) [-0.74, -0.43], while placebo administration produced a small-to-medium effect, Cohen's d = -0.39, 95% CI [-0.52, -0.26]. Meta-regression revealed that cannabinoids, β = -0.43, 95% CI [-0.62, -0.24], p < .05, synthetic cannabinoids, β = -0.39, 95% CI [-0.65, -0.14], p < .05, and sample size, β = 0.01, 95% CI [0.00, 0.01], p < .05, were associated with marked pain reduction. These outcomes suggest that cannabinoid-based pharmacotherapies may serve as effective replacement/adjunctive options regarding pain, however, additional research is warranted. Additionally, given demonstrated neurocognitive side effects associated with some constituent cannabinoids (i.e., THC), subsequent work may consider developing novel therapeutic agents that capitalize on cannabis's analgesic properties without producing adverse effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Collapse
Affiliation(s)
- Julio A. Yanes
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Zach E. McKinnell
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Meredith A. Reid
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Jessica N. Busler
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Jesse S. Michel
- Department of Psychology, Auburn University, Auburn, AL, USA
| | | | | | - Jared W. Younger
- Department of Psychology, University of Alabama Birmingham, Birmingham, AL, USA
| | - Raul Gonzalez
- Department of Psychology, Florida International University, Miami, FL, USA
| | - Jennifer L. Robinson
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| |
Collapse
|
5
|
Synthetic colloid resuscitation in severely injured patients: analysis of a nationwide trauma registry (TraumaRegister DGU). Sci Rep 2018; 8:11567. [PMID: 30068966 PMCID: PMC6070577 DOI: 10.1038/s41598-018-30053-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/24/2018] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to investigate the efficacy and safety of synthetic colloid resuscitation among severely injured patients. Fluid resuscitation of trauma patients of a nationwide trauma registry was analysed between 2002 and 2015. Effects of synthetic colloid resuscitation in the pre-hospital setting and emergency department on renal failure, renal replacement therapy and multiple organ failure were analysed among patients with ≥2 days intensive care unit stay, and in-hospital mortality was analysed among all patients. 48,484 patients with mean age of 49 years and mean injury severity score of 23 points were included; 72.3% were male and 95.5% had blunt trauma. Risk-adjusted analyses revealed that patients receiving >1,000 ml synthetic colloids experienced an increase of renal failure and renal replacement therapy rates (OR 1.42 and 1.32, respectively, both p ≤ 0.006). Any synthetic colloid use was associated with an increased risk of multiple organ failure (p < 0.001), but there was no effect on hospital mortality (p = 0.594). Between 2002 and 2015 usage of synthetic colloids dropped, likewise did total fluid intake and usage of blood products. The data from this analysis suggests that synthetic colloid resuscitation provides no beneficial effects and might be harmful in patients with severe trauma.
Collapse
|
6
|
Wiedermann C, Eisendle K. Acute kidney injury in critically burned patients treated with hydroxyethyl starch: a response to Sánchez-Sánchez et al. ANNALS OF BURNS AND FIRE DISASTERS 2017; 30:220-221. [PMID: 29849528 PMCID: PMC5946756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/12/2017] [Indexed: 06/08/2023]
Affiliation(s)
- C.J. Wiedermann
- Department of Research, College of Health Professions ‘Claudiana’, Bolzano, Italy
- Department of Internal Medicine, Central Hospital of Bolzano, Bolzano, Italy
| | - K. Eisendle
- Department of Research, College of Health Professions ‘Claudiana’, Bolzano, Italy
- Department of Dermatology, Central Hospital of Bolzano, Bolzano, Italy
| |
Collapse
|
8
|
Abstract
Human serum albumin (HSA) is the predominant product of hepatic protein synthesis and one of the more abundant plasma proteins. HSA is a monomeric multidomain macromolecule, representing the main determinant of plasma oncotic pressure and the main modulator of fluid distribution between body compartments. HSA displays an essential role in maintaining the integrity of the vascular barrier. HSA is the most important antioxidant capacity of human plasma, in addition to its ability to protect the body from the harmful effects of heavy metals such as iron and copper and reduce their ability to produce reactive oxygen radicals. HSA is the main depot for nitric oxide (NO) transport in the blood. HSA represents the main carrier for fatty acids, affects pharmacokinetics of many drugs, and provides the metabolic modification of some drugs and displays pseudo-enzymatic properties. HSA has been widely used successfully for more than 50 years in many settings of perioperative medicine including hypovolemia, shock, burns, surgical blood loss, sepsis, and acute respiratory distress syndrome (ARDS). Recently, the use of HSA has shown a promising neuroprotective effect in patients with subarachnoid hemorrhage. The most recent evidence-based functions and uses of HSA in the perioperative period are reviewed in this chapter.
Collapse
Affiliation(s)
- Ehab Farag
- grid.254293.b0000000404350569Cleveland Clinic Lerner College of Medicine Director of Clinical Research Staff Anesthesiologist General Anesthesia and Outcomes Research Cleveland Clinic, Cleveland, Ohio USA
| | - Andrea Kurz
- grid.254293.b0000000404350569Cleveland Clinic Lerner College of Medicine Chairman of General Anesthesia Cleveland Clinic, Cleveland, Ohio USA
| |
Collapse
|