1
|
Allman-Farinelli M, Boljevac B, Vuong T, Hekler E. Nutrition-Related N-of-1 Studies Warrant Further Research to Provide Evidence for Dietitians to Practice Personalized (Precision) Medical Nutrition Therapy: A Systematic Review. Nutrients 2023; 15:nu15071756. [PMID: 37049595 PMCID: PMC10097352 DOI: 10.3390/nu15071756] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/14/2023] Open
Abstract
N-of-1 trials provide a higher level of evidence than randomized controlled trials for determining which treatment works best for an individual, and the design readily accommodates testing of personalized nutrition. The aim of this systematic review was to synthesize nutrition-related studies using an N-of-1 design. The inclusion criterion was adult participants; the intervention/exposure was any nutrient, food, beverage, or dietary pattern; the comparators were baseline values, a control condition untreated or placebo, or an alternate treatment, alongside any outcomes such as changes in diet, body weight, biochemical outcomes, symptoms, quality of life, or a disease outcome resulting from differences in nutritional conditions. The information sources used were Medline, Embase, Scopus, Cochrane Central, and PsychInfo. The quality of study reporting was assessed using the Consort Extension for N-of-1 trials (CENT) statement or the STrengthening Reporting of OBservational Studies in Epidemiology (STROBE) guidelines, as appropriate. From 211 articles screened, a total of 7 studies were included and were conducted in 5 countries with a total of 83 participants. The conditions studied included prediabetes, diabetes, irritable bowel syndrome, weight management, and investigation of the effect of diet in healthy people. The quality of reporting was mostly adequate, and dietary assessment quality varied from poor to good. The evidence base is small, but served to illustrate the main characteristics of N-of-1 study designs and considerations for moving research forward in the era of personalized medical nutrition therapy.
Collapse
Affiliation(s)
- Margaret Allman-Farinelli
- Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
- The Charles Perkins Centre, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Brianna Boljevac
- Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Tiffany Vuong
- Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Eric Hekler
- The Design Lab, University of California San Diego, San Diego, CA 92093, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA 92093, USA
| |
Collapse
|
2
|
Examining negative affect, sleep duration, and using food to cope as predictors of weight in midlife women. J Behav Med 2022; 45:894-903. [PMID: 35933573 DOI: 10.1007/s10865-022-00338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/20/2022] [Indexed: 10/15/2022]
Abstract
Midlife women are vulnerable to developing obesity. Behavioral and psychosocial factors including sleep duration, stress eating, and negative emotionality are risk factors. However, little is known about the complex daily interplay between sleep, eating, emotion, and weight among midlife women. The current study examined how daily sleep, using food to cope, and negative emotionality are associated with weight using a daily process research design. An archival analysis was performed using the Midlife in the United States-II study (MIDUS II). The sample consisted of 489 midlife women (40-64 years of age). Variables included ecological momentary assessments of daily sleep duration, using food to cope, and negative affect (means and intraindividual variability) and a standardized measurement of BMI. Sleep duration variability was a significant predictor of BMI, albeit the model only accounted for .8% of the variance in BMI (b = .019, p < .05). In the final adjusted model, sleep duration variability, using food to cope, age, and physical activity were all significant predictors of BMI F(5, 559) = 21.503, p < .001, R2 = .161, ⨂R2 = .024, p = .001. Variability in negative affect, mean sleep duration or negative affect and the interactions between sleep duration (mean, variability) and negative affect (mean, variability) were not significant. Greater variability in sleep duration and greater use of food to cope predicted higher BMI in this sample across age and physical activity levels. Results highlight that daily health and psychosocial factors play an important role in weight.
Collapse
|
3
|
He W, Cui Z, Chen Y, Wang F, Li F. Status of N-of-1 Trials in Chronic Pain Management: A Narrative Review. Pain Ther 2021; 10:1013-1028. [PMID: 34528159 PMCID: PMC8586287 DOI: 10.1007/s40122-021-00314-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022] Open
Abstract
N-of-1 trials are randomized controlled clinical trials conducted exclusively on a single patient. The ultimate aim of N-of-1 trials is to optimize a strategy in a particular individual. Chronic pain is a common but refractory clinical problem. Its diverse etiologies and broad variations among patients often lead to the requirement of individualizing medicine. Thus, chronic pain represents a classical condition for N-of-1 clinical trials. Studies have indicated that N-of-1 benefits patients with chronic pain, multiple comorbidities, and uncertain variations during therapies; however, this approach it is not yet adopted as the first choice in pain clinics. To dissect the current status of N-of-1 in chronic pain management, as well as the limitations for its implementation, we herein studied all N-of-1 studies related to chronic pain by searching three major databases (PubMed, ClinicalTrial.gov, Cochrane Library) for publications between 1985 and 2020. Of 35 eligibility papers, 19 were selected for analysis. Results confirmed that N-of-1 trials have solved the refractory cases including osteoarthritis, chronic musculoskeletal pain, and neuropathic pain; however, none of the trials dealt with cancer pain. Longer time and more efforts are needed from investigators when carrying out N-of-1 trials, which inevitably result in implementation difficulties. Of note, all recruited trials were conducted in developed countries. As mobile devices have been introduced and protocols improve, renewed interest in the implementation of N-of-1 trials will occur. Collectively, a previously underestimated conflict between "precision medicine" and "poor implementation" has put N-of-1 in a challenging position for chronic pain management.
Collapse
Affiliation(s)
- Wanying He
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| | - Zichan Cui
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| | - Yin Chen
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| | - Fang Wang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Er Road, Guangzhou, 510080 China
| | - Fengxian Li
- Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Road, Guangzhou, 510282 China
| |
Collapse
|
4
|
Tatum WO, Calado G. Class IV studies, meta-analyses, meta-syntheses-Scope and limitations. Seizure 2020; 76:179-180. [PMID: 32169827 DOI: 10.1016/j.seizure.2020.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- William O Tatum
- Mayo Clinic College of Medicine & Health Sciences, Mayo Clinic, Jacksonville, FL, USA.
| | - Gabriel Calado
- Mayo Clinic College of Medicine & Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
5
|
Schreiber DR, Dautovich ND. Sleep Duration as an Indirect Link Between Sleep Timing and Weight in Midlife Women. J Womens Health (Larchmt) 2019; 28:1543-1554. [PMID: 31170032 PMCID: PMC7366270 DOI: 10.1089/jwh.2018.7088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objective: Midlife women are at risk of obesity. Poor sleep outcomes including inadequate sleep duration and variable sleep timing are risk factors for obesity, but there is a lack of understanding on how specific sleep constructs uniquely or concurrently are associated with weight outcomes in this population. This study examined the unique association of sleep timing with weight outcomes and how sleep timing works in conjunction with sleep duration to influence weight in midlife women. Materials and Methods: An archival analysis was performed using the Midlife in the United States-II study (MIDUS-II). The sample consisted of 132 midlife women (40-64; M = 52.9, standard deviation = 6.94). Sleep timing (mean sleep time, variability) and duration were measured through actigraphy and daily sleep diaries. Weight was assessed using body mass index (BMI) and waist circumference measures. Results: PROCESS mediation and moderation analyses assessed direct, indirect, and moderating pathways. Sleep duration emerged as an indirect link between sleep timing (mean and variability) and weight outcomes (95% CI = 0.0001-0.0123; 95% CI = 0.0007-0.0378; 95% CI = 0.0079-0.1006). Sleep timing (95% CI = -0.0144 to 0.0076; 95% CI = -0.0358 to 0.0219) and sleep time variability (95% CI = -0.0124 to 0.0438; 95% CI = -0.0533 to 0.0939) were not directly associated with BMI or waist circumference. Also, sleep timing and duration did not interact to influence weight outcomes. Conclusions: Sleep duration, rather than sleep timing, is associated with weight outcomes, and is an indirect link in the sleep timing and weight outcomes association. Future work is needed to further disentangle the impact of sleep on weight in midlife women using prospective studies, implementing daily assessments of sleep behavior.
Collapse
Affiliation(s)
- Dana R. Schreiber
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia
| | | |
Collapse
|
6
|
Margolis A, Giuliano C. Making the switch: From case studies to N-of-1 trials. Epilepsy Behav Rep 2019; 12:100336. [PMID: 31754660 PMCID: PMC6854058 DOI: 10.1016/j.ebr.2019.100336] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 09/11/2019] [Accepted: 09/18/2019] [Indexed: 11/25/2022] Open
Abstract
Case studies can generate hypothesis based on unique clinical patient encounters and provide guidance among populations with limited numbers of patients. However, case studies are not blinded and are susceptible to a variety of factors that can influence study outcomes. One potential solution to minimize this bias is to use an N-of-1 trial. N-of-1 trials are a double-blinded randomized crossover trial within a limited number of patients, often as small as a single patient. These trials borrow many concepts from randomized controlled trials (RCTs), which in turn increases the validity of findings compared with a case report. Situations best suited for an N-of-1 trial include chronic disease states and therapies with quick onset and offset, such as in patients with seizures. There are many opportunities to use N-of-1 trials among patients with epilepsy, and providers are encouraged to explore and employ these methods. The purpose of this article was to describe N-of-1 trials along with considerations for conducting, publishing, and evaluating N-of-1 trials. The use of N-of-1 trials can minimize bias found in traditional case studies. N-of-1 trials are a double-blinded randomized crossover trial within a single patient. There are methods and reporting standards to guide the development and interpretation of N-of-1 trials.
Collapse
Affiliation(s)
- Amanda Margolis
- University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States of America
| | - Christopher Giuliano
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, 259 Mack Ave, Detroit, MI 48201, United States of America
| |
Collapse
|
7
|
Ferreira JJ, Mestre T, Guedes LC, Coelho M, Rosa MM, Santos AT, Barra M, Sampaio C, Rascol O. Espresso Coffee for the Treatment of Somnolence in Parkinson's Disease: Results of n-of-1 Trials. Front Neurol 2016; 7:27. [PMID: 27014181 PMCID: PMC4782159 DOI: 10.3389/fneur.2016.00027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/22/2016] [Indexed: 12/05/2022] Open
Abstract
There is limited information available concerning the treatment of daytime somnolence associated with Parkinson’s disease (PD); the most frequently applied therapeutic strategies include decreasing the dose of dopamine agonists or adding potential wake-promoting agents. There is recent data from a placebo-controlled trial concluding on a non-significant trend in favor of caffeine. We aimed to evaluate the efficacy of espresso-coffee in the treatment of daytime somnolence in PD. To evaluate the efficacy of espresso-coffee in the treatment of daytime somnolence in PD, we have conducted multiple single-patient (n-of-1) clinical trials comparing regular espresso coffee to decaffeinated coffee in PD patients presenting moderate to severe daytime somnolence defined as an Epworth Sleepiness Scale score >9. Each single-patient (n-of-1) trial included a sequence of three crossovers (two treatment periods separated by two days of washout). Four patients were included in the studies and three completed the three pairs of treatment periods. In two of the four patients, espresso coffee was considered beneficial. This study concludes that multiple single patient trials are feasible in PD and suggests that espresso-coffee may have a beneficial effect on daytime somnolence in some patients. These results cannot be generalized beyond the patients included in these trials.
Collapse
Affiliation(s)
- Joaquim J Ferreira
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Tiago Mestre
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Leonor Correia Guedes
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Miguel Coelho
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Mário M Rosa
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Ana T Santos
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Márcio Barra
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Cristina Sampaio
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Olivier Rascol
- Departments of Clinical Pharmacology and Neurosciences, University Hospital of Toulouse and Clinical Investigation Center INSERM CIC9302 and UMR825, University of Toulouse III , Toulouse , France
| |
Collapse
|
8
|
Langevin P, Peloso PMJ, Lowcock J, Nolan M, Weber J, Gross A, Roberts J, Goldsmith CH, Graham N, Burnie SJ, Haines T. WITHDRAWN: Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Rev 2015; 2015:CD008626. [PMID: 25994306 PMCID: PMC10637244 DOI: 10.1002/14651858.cd008626.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy The editorial group responsible for this previously published document have withdrawn it from publication.
Collapse
Affiliation(s)
- Pierre Langevin
- Département de réadaptation, Faculté de Médecine, Université LavalCliniques Physio Interactive3520 rue de l'HêtrièreSt‐Augustin‐de‐DesmauresQCCanadaG3A 2V4
| | - Paul Michael J Peloso
- MRL ‐ MerckDepartment of Clinical DevelopmentRY34‐B272126 E. Lincoln AveRahwayNJUSA07065
| | | | - May Nolan
- University of British ColumbiaSchool of Physiotherapy, Faculty of Medicine212‐2177 Westbrook MallVancouverBCCanadaV6T 1Z3
| | - Jeff Weber
- Family Physiotherapy Inc.G04, 7408 ‐ 139th AvenueEdmontonABCanadaT5C 3H7
| | - Anita Gross
- McMaster UniversitySchool of Rehabilitation Science & Department of Clinical Epidemiology and Biostatistics1400 Main Street WestHamiltonONCanadaL8S 1C7
| | - John Roberts
- University of Calgary Sport Medicine CentrePhysiotherapy Department302 838 4th Ave NWCalgaryABCanadaT2N 0M8
| | - Charles H Goldsmith
- Simon Fraser UniversityFaculty of Health SciencesBlossom Hall, Room 95108888 University DriveBurnabyBCCanadaV5A 1S6
| | - Nadine Graham
- McMaster UniversitySchool of Rehabilitation Science1200 Main Street WestHamiltonONCanada
| | - Stephen J Burnie
- Canadian Memorial Chiropractic CollegeDepartment of Clinical Education6100 Leslie StreetTorontoONCanadaM2H 3J1
| | - Ted Haines
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHSC 3H54HamiltonONCanadaL8N 3Z5
| | | |
Collapse
|
9
|
Peloso PMJ, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie SJ. WITHDRAWN: Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev 2015; 2015:CD000319. [PMID: 25994305 PMCID: PMC10798413 DOI: 10.1002/14651858.cd000319.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy The editorial group responsible for this previously published document have withdrawn it from publication.
Collapse
Affiliation(s)
- Paul Michael J Peloso
- MRL ‐ MerckDepartment of Clinical DevelopmentRY34‐B272126 E. Lincoln AveRahwayNJUSA07065
| | - Anita Gross
- McMaster UniversitySchool of Rehabilitation Science & Department of Clinical Epidemiology and Biostatistics1400 Main Street WestHamiltonONCanadaL8S 1C7
| | - Ted Haines
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHSC 3H54HamiltonONCanadaL8N 3Z5
| | - Kien Trinh
- McMaster UniversityDeGroote School of Medicine, Office of MD Admissions1200 Main Street WestMDCL‐3112HamiltonONCanadaL8N 3Z5
| | - Charles H Goldsmith
- Simon Fraser UniversityFaculty of Health SciencesBlossom Hall, Room 95108888 University DriveBurnabyBCCanadaV5A 1S6
| | - Stephen J Burnie
- Canadian Memorial Chiropractic CollegeDepartment of Clinical Education6100 Leslie StreetTorontoONCanadaM2H 3J1
| | | | | |
Collapse
|
10
|
Al-Zadjali M, Keller C, Larkey L, Evans B. GCC women: causes and processes of midlife weight gain. Health Care Women Int 2014; 35:1267-86. [PMID: 24628569 DOI: 10.1080/07399332.2014.900557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Perimenopausal obesity is a particular problem in Gulf Cooperation Council (GCC) countries. This study examined the culturally specific views of perimenopausal GCC women, and the causes and processes of midlife weight gain using a qualitative descriptive design with semistructured interviewing and content analysis. Constructs derived from the health belief model and Kleiman's explanatory model were used to identify and sort themes into conceptual categories. The findings of this study suggest that weight-management program plans targeting perimenopausal GCC women should take into consideration the multiple levels of factors and cultural influences on their behavior.
Collapse
Affiliation(s)
- Manal Al-Zadjali
- a College of Nursing and Health Innovation , Arizona State University , Phoenix , Arizona , USA
| | | | | | | |
Collapse
|
11
|
Pimenta F, Maroco J, Ramos C, Leal I. Predictors of weight variation and weight gain in peri- and post-menopausal women. J Health Psychol 2013; 19:993-1002. [DOI: 10.1177/1359105313483153] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This research encompasses a community sample of 497 women in peri- and post-menopause and uses structural equation modelling to investigate the structural models of weight variation and weight gain. Variables such as body shape concerns, depression, stress and life events are explored. Weight gain (from pre-menopause to current menopausal status) was observed in 69 per cent of participants. The predictors of weight gain were lower education level ( β = −.146, p = .017), less or no physical exercise ( β = −.111, p = .021), having a recent psychological problem ( β = .191, p < .001), transition from peri- to post-menopause ( β = .147, p = .013) and more frequent body shape concerns ( β = .313, p < .001). Prevention of weight gain in pre-menopause is recommended; risk groups should be targeted considering the predictors of weight increase.
Collapse
|
12
|
Goldenberg JZ, Wenner CA. A Novel N of 1 Trial Design and Proposed Utility in Complementary and Alternative Medicine Research. J Evid Based Complementary Altern Med 2012. [DOI: 10.1177/2156587212437556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An N of 1 trial is a multiple crossover study in a single participant. N of 1trials can combine the benefits of individualized patient practice and evidence-based medicine and are amenable to complementary and alternative medicine practice and research. This article will review the basic structure of N of 1trials, discuss how they are commonly used, and review their limitations and statistical considerations. The authors also propose a novel use of the N of 1 trial in the form of mixed-methodology add-on N of 1 trials targeted to a parent trial’s responders. This design can help uncover evidence of subgroup effects in small trials, address issues surrounding the small study effect, and explore the role of interparticipant variability and random chance in the parent trial.
Collapse
|
13
|
Langevin P, Peloso PMJ, Lowcock J, Nolan M, Weber J, Gross A, Roberts J, Goldsmith CH, Graham N, Burnie SJ, Haines T. Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Rev 2011:CD008626. [PMID: 21735434 DOI: 10.1002/14651858.cd008626.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain. OBJECTIVES To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder. SEARCH STRATEGY We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome. MAIN RESULTS We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies.High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)). AUTHORS' CONCLUSIONS Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.
Collapse
Affiliation(s)
- Pierre Langevin
- Cliniques Physio Interactive, Département de réadaptation, Faculté de Médecine, Université Laval, 1100 boul Chaudière, CP 75217, Quebec City, PQ, Canada, G1Y 3C7
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Marketing therapeutic precision: Potential facilitators and barriers to adoption of n-of-1 trials. Contemp Clin Trials 2009; 30:436-45. [PMID: 19375521 DOI: 10.1016/j.cct.2009.04.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 04/03/2009] [Accepted: 04/10/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND N-of-1 trials may enhance therapeutic precision by predicting the long-term effectiveness of medical treatment on an individual basis. However, the n-of-1 approach has gained little traction with the clinical community. To learn why, we interviewed physicians and patients, focusing on the perceived benefits and drawbacks of n-of-1 trials and factors influencing these perceptions. METHODS We convened focus groups and individual interviews with 21 physicians and 32 patients, most with chronic conditions. The study employed qualitative interview methods to explore and analyze subjects' views of n-of-1 trials. Analysis involved an iterative process of review and data abstraction after specific topics for coding, definitions of codes, and strategies for abstraction had been established. Previously defined domains and topics were then expanded and enriched, with key themes emerging during the analytic process. RESULTS Physicians and patients remarked on 4 salient aspects of n-of-1 trials: scientific, relational, clinical, and logistical. Neither physicians nor patients were highly familiar with the n-of-1 concept, but both groups readily grasped the fundamental logic and appreciated the potential scientific benefits. Physicians saw n-of-1 trials as promoting an exciting but possibly threatening paradigm shift in the doctor-patient relationship, while patients viewed the relational consequences as modest. The best n-of-1 candidates were felt to be proactive, cognitively intact, reliable, motivated, and engaged in a trusting physician-patient relationship. CONCLUSIONS Researchers interested in expanding the appeal of n-of-1 trials will need to address these concerns by carefully explaining the approach, emphasizing the benefits, and minimizing the effort required of doctors and patients.
Collapse
|
15
|
Kravitz RL, Duan N, Niedzinski EJ, Hay MC, Subramanian SK, Weisner TS. What ever happened to N-of-1 trials? Insiders' perspectives and a look to the future. Milbank Q 2009; 86:533-55. [PMID: 19120979 DOI: 10.1111/j.1468-0009.2008.00533.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
CONTEXT When feasible, randomized, blinded single-patient (n-of-1) trials are uniquely capable of establishing the best treatment in an individual patient. Despite early enthusiasm, by the turn of the twenty-first century, few academic centers were conducting n-of-1 trials on a regular basis. METHODS The authors reviewed the literature and conducted in-depth telephone interviews with leaders in the n-of-1 trial movement. FINDINGS N-of-1 trials can improve care by increasing therapeutic precision. However, they have not been widely adopted, in part because physicians do not sufficiently value the reduction in uncertainty they yield weighed against the inconvenience they impose. Limited evidence suggests that patients may be receptive to n-of-1 trials once they understand the benefits. CONCLUSIONS N-of-1 trials offer a unique opportunity to individualize clinical care and enrich clinical research. While ongoing changes in drug discovery, manufacture, and marketing may ultimately spur pharmaceutical makers and health care payers to support n-of-1 trials, at present the most promising resuscitation strategy is stripping n-of-1 trials to their essentials and marketing them directly to patients. In order to optimize statistical inference from these trials, empirical Bayes methods can be used to combine individual patient data with aggregate data from comparable patients.
Collapse
|
16
|
Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev 2007:CD000319. [PMID: 17636629 DOI: 10.1002/14651858.cd000319.pub4] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Controversy persists regarding medicinal therapies and injections. OBJECTIVES To determine the effects of medication and injections on primary outcomes (e.g. pain) for adults with mechanical neck disorders and whiplash. SEARCH STRATEGY We searched CENTRAL, MANTIS, CINAHL from their start to May 2006; MEDLINE and EMBASE to December 2006. We scrutinised reference lists for other trials. SELECTION CRITERIA We included randomised controlled trials with adults with neck disorders, with or without associated headache or radicular findings. We considered medicinal and injection therapies, regardless of route of administration. DATA COLLECTION AND ANALYSIS Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random-effects models. MAIN RESULTS We found 36 trials that examined the effects of oral NSAIDs, psychotropic agents, steroid injections, and anaesthetic agents. Trials had a mean of 3.1 on the Jadad Scale for methodological quality; 70% were high quality. For acute whiplash, administering intravenous methylprednisolone within eight hours of injury reduced pain at one week (SMD -0.90, 95% CI -1.57 to -0.24), and sick leave but not pain at six months compared to placebo in one trial. For chronic neck disorders at short-term follow-up, intramuscular injection of lidocaine was superior to placebo (SMD -1.36, 95% CI -1.93 to -0.80); NNT 3, treatment advantage 45% and dry needling, but similar to ultrasound in one trial each. In chronic neck disorders with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain and improved function more than when given by intramuscular route at one-year follow-up, in one trial. In subacute and chronic neck disorders, muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits. In participants with chronic neck disorders with or without radicular findings or headache, there was moderate evidence from five high quality trials that Botulinum toxin A intramuscular injections had similar effects to saline in improving pain (pooled SMD: -0.39, 95%CI -1.25 to 0.47), disability or global perceived effect. AUTHORS' CONCLUSIONS The major limitations are the lack of replication of the findings and sufficiently large trials. There is moderate evidence for the benefit of intravenous methylprednisolone given within eight hours of acute whiplash, from a single trial. Lidocaine injection into myofascial trigger points appears effective in two trials. There is moderate evidence that Botulinum toxin A is not superior to saline injection for chronic MND. Muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.
Collapse
Affiliation(s)
- P Peloso
- Amgen, Inc, One Amgen Center Drive, MS 38-2-C, Thousand Oaks, California 91320, USA.
| | | | | | | | | | | |
Collapse
|
17
|
Brookes ST, Biddle L, Paterson C, Woolhead G, Dieppe P. "Me's me and you's you": Exploring patients' perspectives of single patient (n-of-1) trials in the UK. Trials 2007; 8:10. [PMID: 17371593 PMCID: PMC1831792 DOI: 10.1186/1745-6215-8-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Accepted: 03/19/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The n-of-1 trial offers a more methodologically sound approach to determining optimum treatment for an individual patient than "trials of therapy" routinely conducted in clinical practice. However, such methodology is rarely used in the UK. This pilot study explores the acceptability of n-of-1 trials to patients in the UK. METHODS Patients with osteoarthritis of the knee were recruited to their own 12-week n-of-1 trial comparing either two knee supports or an NSAID with simple analgesic. Patients were interviewed at the start and completion of their trial to explore reasons for participation, understanding of the trial design and experiences of participation. Daily diaries were completed to inform future treatment. RESULTS Nine patients participated (5 supports, 4 drugs). Patients were keen to participate, believing that the trial may lead to personal gains such as improved symptom control and quality of life. However, recruitment to the pharmacological comparison was more difficult since this could also entail risk. All patients were eager to complete the trial, even when difficulties were encountered. Completing the daily diary provided some patients with greater insight into their condition, which allowed them to improve their self-management. The n-of-1 trial design was viewed as a 'logical' design offering an efficient method of reaching a personalised treatment decision tailored to suit individual needs and preferences. CONCLUSION This pilot study suggests that patients perceive the n-of-1 trial as an acceptable approach to the individualisation of treatment. In addition, further benefits over and above any gained from the interventions can be derived from involvement in such a study.
Collapse
Affiliation(s)
- Sara T Brookes
- Department of Social Medicine, University of Bristol, UK
| | - Lucy Biddle
- Department of Social Medicine, University of Bristol, UK
| | - Charlotte Paterson
- MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, UK
| | | | - Paul Dieppe
- MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, UK
| |
Collapse
|
18
|
Wegman ACM, van der Windt DAWM, Stalman WAB, de Vries TPGM. Conducting research in individual patients: lessons learnt from two series of N-of-1 trials. BMC FAMILY PRACTICE 2006; 7:54. [PMID: 16984636 PMCID: PMC1599734 DOI: 10.1186/1471-2296-7-54] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Accepted: 09/19/2006] [Indexed: 12/01/2022]
Abstract
Background Double-blind randomised N-of-1 trials (N-of-1 trials) may help with decisions concerning treatment when there is doubt regarding the effectiveness and suitability of medication for individual patients. The patient is his or her own control, and receives the experimental and the control treatment during several periods of time in random order. Reports of N-of-1 trials are still relatively scarce, and the research methodology is not as firmly established as that of RCTs. Recently, we have conducted two series of N-of-1 trials in general practice. Before, during, and after data-collection, difficulties regarding outcome assessment, analysis of the results, the withdrawal of patients, and the follow-up had to be dealt with. These difficulties are described and our solutions are discussed. Discussion To prevent or anticipate difficulties in N-of-1 trials, we argue that that it is important to individualise the outcome measures, and to carefully consider the objective, type of randomisation and the analysis. It is recommended to use the same dosages and dosage forms that the patient used before the trial, to start the trial with a run-in period, to formulate both general and individualised decision rules regarding the efficacy of treatment, to adjust treatment policies immediately after the trial, and to provide adequate instructions and support if treatment is adjusted. Summary Because of the specific characteristics of N-of-1 trials it is difficult to formulate general 'how to do it' guidelines for designing N-of-1 trials. However, when the design of each N-of-1 trial is tailored to the specific characteristics of each individual patient and the underlying medical problem, most difficulties in N-of-1 trials can be prevented or overcome. In this way, N-of-1 trials may be of help when deciding on drug treatment for individual patients.
Collapse
Affiliation(s)
- Anke CM Wegman
- Department of Pharmacology/Pharmacotherapy, VU University medical center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Daniëlle AWM van der Windt
- EMGO Institute and Department of General Practice, VU University medical center, Amsterdam, The Netherlands
- Primary Care Sciences Research Centre, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Wim AB Stalman
- EMGO Institute and Department of General Practice, VU University medical center, Amsterdam, The Netherlands
| | - Theo PGM de Vries
- Department of Pharmacology/Pharmacotherapy, VU University medical center, Amsterdam, The Netherlands
| |
Collapse
|
19
|
Nikles CJ, Yelland M, Del Mar C, Wilkinson D. The role of paracetamol in chronic pain: an evidence-based approach. Am J Ther 2005; 12:80-91. [PMID: 15662295 DOI: 10.1097/00045391-200501000-00011] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic pain is a significant public health burden. Several international guidelines and influential reviews recommend the use of paracetamol (acetaminophen) as the first-line analgesic of choice for the management of chronic pain. These recommendations are based largely on the balance of evidence, which favorably demonstrates the efficacy, safety, and low cost of paracetamol relative to other analgesics.A decade ago, March et al suggested that because of the dangers associated with conventional nonsteroidal antiinflammatory (NSAID) use, particularly in the elderly, they should ideally not be used without an individual n-of-1 trial to show that they are more effective than paracetamol. Today, the results of our investigations into the individualization of pain management options continue to support this suggestion. Based on the data available to date, it still seems prudent to use NSAIDs only in those patients in whom there is good evidence of improved efficacy over paracetamol. In patients with chronic pain, paracetamol can play an important role as an NSAID sparer, with resultant benefits in terms of reduced adverse effects and cost savings.
Collapse
Affiliation(s)
- C Jane Nikles
- Discipline of General Practice, The University of Queensland, Herston, Herston, Queensland 4006, Australia.
| | | | | | | |
Collapse
|
20
|
Nikles CJ, Yelland M, Glasziou PP, Del Mar C. Do individualized medication effectiveness tests (n-of-1 trials) change clinical decisions about which drugs to use for osteoarthritis and chronic pain? Am J Ther 2005; 12:92-7. [PMID: 15662296 DOI: 10.1097/00045391-200501000-00012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
To assess the impact of individualized medication effectiveness tests (IMETs, or n-of-1 trials), on patients' short-term decision making about medications for chronic pain. Survey evaluation of patients undergoing a double-blind, crossover comparison of drug versus placebo, drug versus drug, or drug versus drug combination using paracetamol and ibuprofen in 3 pairs of treatment periods, randomized within pairs. General practice patients (supplemented by a few from 2 tertiary pain clinics) with either chronic pain (> or =3 months), or osteoarthritis (with pain for > or =1 month) severe enough to warrant consideration of long-term nonsteroidal antiinflammatory drug (NSAID) use but for whom there was doubt about the efficacy of NSAID or alternative. Pain and stiffness in sites nominated by the patient, global pain, use of escape analgesia, and side effects. Of 116 IMETs started, 71 were completed. Drug management changed for 46 of 71 (65%). The most common change was to add paracetamol or to substitute the NSAID or COX-2 inhibitor with paracetamol (25 of 71 patients and 54% of changes). Of the 37 who were using NSAIDs or COX-2 inhibitors before the IMET, 12 (32%) ceased these afterward. Paracetamol was as effective or more effective than ibuprofen in 37 (68%) of the 54 IMETs directly comparing these drugs. IMETs provide useful information for clinical decisions. Paracetamol continues to be useful for patients with chronic pain whose optimal drug choice is in doubt. Our results provide a new (individual) perspective on the well-known recommendation for paracetamol as first-line treatment for chronic pain and demonstrate that it is feasible to provide IMETs nationally by mail and telephone.
Collapse
Affiliation(s)
- C Jane Nikles
- Discipline of General Practice, The University of Queensland, Herston, Queensland, Australia.
| | | | | | | |
Collapse
|
21
|
Lee C, Straus WL, Balshaw R, Barlas S, Vogel S, Schnitzer TJ. A comparison of the efficacy and safety of nonsteroidal antiinflammatory agents versus acetaminophen in the treatment of osteoarthritis: A meta-analysis. ACTA ACUST UNITED AC 2004; 51:746-54. [PMID: 15478167 DOI: 10.1002/art.20698] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To perform a meta-analysis comparing the efficacy and safety of recommended dosages of nonsteroidal antiinflammatory drugs (NSAIDs), including cyclooxygenase 2 inhibitors, versus acetaminophen in the treatment of symptomatic hip and knee osteoarthritis. METHODS Medline and EMBASE searches were performed for original clinical trials directly comparing NSAIDs with acetaminophen. A standardized form was used to abstract all data, including outcome measures of pain at rest, walking pain, and dropouts due to adverse effects. Inverse-variance-weighted mean differences (WMDs) and 95% confidence intervals (95% CI) for pain measures were determined for treatment groups. Odds ratios (ORs) and 95% CIs were calculated for withdrawals due to adverse events. Results were compared using a random effects model. RESULTS Seven articles met inclusion criteria with sufficient data for analysis. Participants had a mean age of 61.1 years and 71.1% were women. Test of heterogeneity was not significant for either rest (P = 0.73) or walking (P = 0.76) pain. The scores for overall pain at rest (WMD -6.33 mm on a 100-mm visual analog scale [VAS], 95% CI -9.24, -3.41) and walking pain (WMD -5.76 mm on a 100-mm VAS, 95% CI -8.99, -2.52) favored the NSAID-treated group. Although NSAIDs elevated the risk of withdrawals due to adverse events, the difference was not statistically significant (OR 1.45, 95% CI 0.93, 2.27). CONCLUSION NSAIDs are statistically superior in reducing rest and walking pain compared with acetaminophen for symptomatic osteoarthritis. Safety, measured by discontinuation due to adverse events, was not statistically different between NSAID- and acetaminophen-treated groups.
Collapse
Affiliation(s)
- Chin Lee
- Northwestern University, The Feinberg School of Medicine, Chicago, Illinois, USA.
| | | | | | | | | | | |
Collapse
|
22
|
Coxeter PD, Schluter PJ, Eastwood HL, Nikles CJ, Glasziou PP. Valerian does not appear to reduce symptoms for patients with chronic insomnia in general practice using a series of randomised n-of-1 trials. Complement Ther Med 2004; 11:215-22. [PMID: 15022653 DOI: 10.1016/s0965-2299(03)00122-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness of valerian for the management of chronic insomnia in general practice. DESIGN Valerian versus placebo in a series of n-of-1 trials, in Queensland, Australia. RESULTS Of 42 enrolled patients, 24 (57%) had sufficient data for inclusion into the n-of-1 analysis. Response to valerian was fair for 23 (96%) participants evaluating their "energy level in the previous day" but poor or modest for all 24 (100%) participants' response to "total sleep time" and for 23 (96%) participants' response to "number of night awakenings" and "morning refreshment". As a group, the proportion of treatment successes ranged from 0.35 (95% CI 0.23, 0.47) to 0.55 (95% CI 0.43, 0.67) for the six elicited outcome sleep variables. There was no significant difference in the number (P=0.06), distribution (P=1.00) or severity (P=0.46) of side effects between valerian and placebo treatments. CONCLUSIONS Valerian was not shown to be appreciably better than placebo in promoting sleep or sleep-related factors for any individual patient or for all patients as a group.
Collapse
Affiliation(s)
- P D Coxeter
- Herbal Medicines Research and Education Center, University of Sydney, Sydney, NSW, Australia
| | | | | | | | | |
Collapse
|
23
|
Wegman ACM, van der Windt DAWM, de Haan M, Devillé WLJM, Fo CTCA, de Vries TPGM. Switching from NSAIDs to paracetamol: a series of n of 1 trials for individual patients with osteoarthritis. Ann Rheum Dis 2004; 62:1156-61. [PMID: 14644852 PMCID: PMC1754410 DOI: 10.1136/ard.2002.002865] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate for individual patients who have been using NSAIDs regularly, whether paracetamol is as effective as non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of pain and disability related to osteoarthritis of the hip or knee. METHODS A series of n of 1 trials were conducted in general practices in Amsterdam and the surrounding area. Each patient was his or her own control and received five pairs of treatments comprising two weeks of an NSAID and two weeks of paracetamol. For each pair, the order of treatments was randomised. Outcome measures were severity of individual main complaints, intensity of pain, satisfaction with drugs, function test, and side effects. RESULTS Thirteen patients were selected. Six patients did not complete the study. For five patients completing the study little or no difference was found between NSAIDs and paracetamol, for one patient the results favoured the NSAID, and for one patient there was no association between outcome and type of drug. It was recommended that six patients changed to paracetamol; the others continued with NSAIDs. Three months after the end of the study, four of the six patients for whom paracetamol had been recommended were taking NSAIDs for practical reasons or perceived lack of efficacy. CONCLUSION The results of the n of 1 trials varied across patients. n of 1 trials can be used to investigate which treatment is best for any specific person, thus avoiding unnecessary prolonged treatment with NSAIDs. However, practical reasons may cause patients to switch from NSAIDs to paracetamol or not.
Collapse
Affiliation(s)
- A C M Wegman
- Department of General Practice, Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
24
|
Del Mar CB, Freeman GK, Van Weel C. "Only a GP?": is the solution to the general practice crisis intellectual? Med J Aust 2003; 179:26-9. [PMID: 12831380 DOI: 10.5694/j.1326-5377.2003.tb05412.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2003] [Accepted: 06/02/2003] [Indexed: 11/17/2022]
Abstract
General practice is suffering a crisis of status, as shown by financial, power and intellectual markers. This is serious as a strong general-practice workforce is important to deliver cost-effective, high-quality healthcare. We argue that strengthening the intellectual aspects of general practice (particularly critical thinking) is essential. Most strategies to achieve this centre on research, with many initiatives in Australia and overseas to enhance research by general practitioners; there is still insufficient clinical research in general practice. Other ways to improve critical thinking include promoting use of evidence-based medicine, provided it is not implemented only via "cook-book" guidelines. Other innovations are desperately needed.
Collapse
Affiliation(s)
- Chris B Del Mar
- Centre for General Practice, University of Queensland Medical School, Herston, QLD 4006, Australia.
| | | | | |
Collapse
|
25
|
Abstract
Pain is a common problem, but unfortunately, it is one that is still notoriously neglected and poorly managed. Although it usually is not rated highly in public health statistics, it forms a substantial proportion of the everyday work of health care professionals, and thus remains a major public health burden. The first challenge in successful pain management is overcoming the ineffective learning processes most health care practitioners use to update their procedures and therapies in response to the latest research. The ready availability of over-the-counter analgesics means that much of the pain in the community is now self-medicated, and it is vital that they also have ready access to the latest evidence-based recommendations. Second, better methods are needed to tailor treatment to individual patients because differences in comorbidities, drug metabolism, or the nature and severity of disease processes lead to different responses from individual patients. Such tailoring should also account for differences in side-effect profiles of the various treatment options available. Finally, even if health practitioners are aware of the latest in clinical evidence and recommended practices, they may not be able to implement the most appropriate treatment because of legal or financial barriers. This article will to review these three challenges to the management of pain and discuss practical ways in which they may be handled to help reduce the burden of pain care in society.
Collapse
Affiliation(s)
- Paul Phillip Glasziou
- School of Population Health, Medical School, University of Queensland, Herston, Australia.
| |
Collapse
|