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Buchbinder R, Busija L. Why we should stop performing vertebroplasties for osteoporotic spinal fractures. Intern Med J 2020; 49:1367-1371. [PMID: 31713338 DOI: 10.1111/imj.14628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/17/2019] [Accepted: 06/23/2019] [Indexed: 11/29/2022]
Abstract
While vertebroplasty enjoys continued use in some settings, there is now high-moderate quality evidence based on systematic review that includes five placebo-controlled trials that it provides no benefits over placebo and these results do not differ according to pain duration (≤6 vs >6 weeks). A clinically important increased risk of incident symptomatic vertebral fractures or other serious adverse events cannot be excluded due to small event numbers. Serious harms including cord compression, ventricular perforation, pulmonary embolism, infection and death have been reported. This unfavourable risk-benefit ratio should be convincing doctors and patients to stop the use of vertebroplasty. At the very least, clinicians should fully inform their patients about the evidence including the likelihood of improving without vertebroplasty and the potential harms, so that patients can make evidence-informed decisions about their treatment. They should also warn patients about the pitfalls of relying on information sourced from the internet or from 'awareness raising' campaigns.
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Affiliation(s)
- Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lucy Busija
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia.,Biostatistics Consulting Platform, Research Methodology Division, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
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Walicke P, Abosch A, Asher A, Barker FG, Ghogawala Z, Harbaugh R, Jehi L, Kestle J, Koroshetz W, Little R, Rubin D, Valadka A, Wisniewski S, Chiocca EA. Launching Effectiveness Research to Guide Practice in Neurosurgery: A National Institute Neurological Disorders and Stroke Workshop Report. Neurosurgery 2017; 80:505-514. [PMID: 28362926 DOI: 10.1093/neuros/nyw133] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 12/12/2016] [Indexed: 11/13/2022] Open
Abstract
This workshop addressed challenges of clinical research in neurosurgery. Randomized controlled clinical trials (RCTs) have high internal validity, but often insufficiently generalize to real-world practice. Observational studies are inclusive but often lack sufficient rigor. The workshop considered possible solutions, such as (1) statistical methods for demonstrating causality using observational data; (2) characteristics required of a registry supporting effectiveness research; (3) trial designs combining advantages of observational studies and RCTs; and (4) equipoise, an identified challenge for RCTs. In the future, advances in information technology potentially could lead to creation of a massive database where clinical data from all neurosurgeons are integrated and analyzed, ending the separation of clinical research and practice and leading to a new "science of practice."
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Affiliation(s)
- Patricia Walicke
- National Institute Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado-Anschutz Medical Campus, Aurora, Co-lorado
| | - Anthony Asher
- Department of Neurosurgery and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Caro-lina
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zoher Ghogawala
- Alan L. and Jacqueline B. Stuart Spine Research Center, Depart-ment of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massa-chusetts; Tufts University School of Medi-cine, Boston, Massachusetts
| | - Robert Harbaugh
- Depart-ment of Neurosurgery, Penn State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | - John Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Walter Koroshetz
- National Institute Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | | | - Donald Rubin
- Department of Statistics, Harvard University, Cam-bridge, Massachusetts
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
| | - Stephen Wisniewski
- Depart-ment of Epidemiology, University of Pittsburg, Pittsburgh, Pennsylvania
| | - E Antonio Chiocca
- Department of Neurosurgery, Brigham and Women's Hospital, Center for Neuro- Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Trends in Inpatient Vertebroplasty and Kyphoplasty Volume in the United States, 2005-2011: Assessing the Impact of Randomized Controlled Trials. Clin Spine Surg 2017; 30:E276-E282. [PMID: 28323712 DOI: 10.1097/bsd.0000000000000207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
STUDY DESIGN Retrospective analysis of the Nationwide Inpatient Sample, 2005-2011. OBJECTIVE To identify trends in procedural volume and rates in the time period surrounding publication of randomized controlled trials (RCTs) that examined the utility of vertebroplasty and kyphoplasty. SUMMARY OF BACKGROUND DATA Vertebroplasty and kyphoplasty are frequently performed for vertebral compression fractures. Several RCTs have been published with conflicting outcomes regarding pain and quality of life compared with nonsurgical management and sham procedures. Four RCTs with discordant results were published in 2009. MATERIALS AND METHODS The Nationwide Inpatient Sample provided longitudinal, retrospective data on United States' inpatients between 2005 and 2011. Inclusion was determined by a principal or secondary International Classification of Diseases, Ninth Revision, Clinical Modification code of 81.65 (percutaneous vertebroplasty) or 81.66 (percutaneous vertebral augmentation; "kyphoplasty"). No diagnoses were excluded. Years were stratified as "pre" (2005-2008) and "post" (2010-2011) in relation to the 4 RCTs published in 2009. Patient, hospital, and admission characteristics were compared using Pearson χ test. RESULTS The estimated annual inpatient procedures performed decreased from 54,833 to 39,832 in the pre and post periods, respectively. The procedural rate for fractures decreased from 20.1% to 14.7% (P<0.0001). Patient and hospital demographics did not change considerably between the time periods. In the post period, weekend admissions increased (34.2% vs. 12.4%, P<0.0001), elective admissions decreased (21.4% vs. 40.0%, P<0.0001), routine discharge decreased (33.0% vs. 52.1%, P<0.0001), and encounters with ≥3 Elixhauser comorbidities increased (54.5% vs. 39.1%, P<0.0001). CONCLUSIONS The absolute rate of inpatient vertebroplasty and kyphoplasty procedures for fractures decreased 5% in the period (2010-2011) following the publication of 4 RCTs in 2009. The proportion of elective admissions and routine discharges decreased, possibly indicating a population with greater disease severity. Although our analysis cannot demonstrate a cause-and-effect relationship, the decreased inpatient volume and procedural rates surrounding the publication of sentinel negative RCTs is clearly observed.
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Smieliauskas F, Lam S, Howard DH. Impact of Negative Clinical Trial Results for Vertebroplasty on Vertebral Augmentation Procedure Rates. J Am Coll Surg 2014; 219:525-33.e1. [DOI: 10.1016/j.jamcollsurg.2014.03.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/04/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
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Kroon F, Staples M, Ebeling PR, Wark JD, Osborne RH, Mitchell PJ, Wriedt CHR, Buchbinder R. Two-year results of a randomized placebo-controlled trial of vertebroplasty for acute osteoporotic vertebral fractures. J Bone Miner Res 2014; 29:1346-55. [PMID: 24967454 DOI: 10.1002/jbmr.2157] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We previously reported the results of a randomized controlled trial that found no benefit of vertebroplasty over a sham procedure for acute osteoporotic vertebral fractures up to 6 months. We report here the 12-month and 24-month clinical outcomes of this trial. Eligible participants (n = 78) were randomly assigned to receive either vertebroplasty (n = 38) or a sham procedure (n = 40). Randomization was stratified by treatment center, sex, and symptom duration (<6 weeks or ≥6 weeks). Participants, investigators (except the treating radiologists), and outcome assessors were blinded to group assignments. Enrolment occurred between April 2004 and October 2008 with follow-up completed October 2010. The primary outcome was overall pain measured on a scale of 0 (no pain) to 10 (maximal imaginable pain). Secondary outcomes included pain at rest and at night, disability, quality of life, perceived recovery, and adverse events, including incident clinically apparent vertebral fractures. At 12 and 24 months, complete data were available for 67 (86%) and 57 (73%) participants, respectively. At 12 months participants in the active group improved by 2.4 ± 2.7 (mean ± SD) units in overall pain compared with 1.9 ± 2.8 units in the sham group, adjusted between-group mean difference (MD) 0.3 (95% confidence interval [CI], –0.9 to 1.5), whereas at 24 months participants in the active group had improved by 3.0 ± 3.1 units compared with 1.9 ± 3.0 units in the sham group, MD 1.1 (95% CI, –0.3 to 2.4). No significant between-group differences were observed for any of the secondary efficacy outcomes at 12 or 24 months. There were no between-group differences in incident clinical vertebral fractures up to 24 months (active: n = 14, sham: n = 13), although the study had inadequate power for this outcome. These results provide further evidence that the use of this treatment in routine care is unsupported.
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Affiliation(s)
- Féline Kroon
- Monash Department of Clinical Epidemiology; Cabrini Institute; Victoria Australia
- Department of Rheumatology; Leiden University Medical Centre; Leiden the Netherlands
| | - Margaret Staples
- Monash Department of Clinical Epidemiology; Cabrini Institute; Victoria Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Victoria Australia
| | - Peter R Ebeling
- NorthWest Academic Centre; University of Melbourne; Western Health Victoria Australia
| | - John D Wark
- University of Melbourne Department of Medicine; and Bone and Mineral Medicine; Royal Melbourne Hospital Victoria Australia
| | - Richard H Osborne
- Public Health Innovation, Population Health Strategic Research Centre; Deakin University; Victoria Australia
| | - Peter J Mitchell
- University of Melbourne; Department of Radiology; Royal Melbourne Hospital Victoria Australia
| | | | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology; Cabrini Institute; Victoria Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Victoria Australia
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Barr JD, Jensen ME, Hirsch JA, McGraw JK, Barr RM, Brook AL, Meyers PM, Munk PL, Murphy KJ, O'Toole JE, Rasmussen PA, Ryken TC, Sanelli PC, Schwartzberg MS, Seidenwurm D, Tutton SM, Zoarski GH, Kuo MD, Rose SC, Cardella JF. Position statement on percutaneous vertebral augmentation: a consensus statement developed by the Society of Interventional Radiology (SIR), American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), Canadian Interventional Radiology Association (CIRA), and the Society of NeuroInterventional Surgery (SNIS). J Vasc Interv Radiol 2013; 25:171-81. [PMID: 24325929 DOI: 10.1016/j.jvir.2013.10.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 10/03/2013] [Accepted: 10/03/2013] [Indexed: 12/23/2022] Open
Affiliation(s)
- John D Barr
- California Center for Neurointerventional Surgery, La Jolla.
| | - Mary E Jensen
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
| | - Joshua A Hirsch
- Division of Neurointerventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - J Kevin McGraw
- Riverside Interventional Consultants, Riverside Methodist Hospital, Columbus
| | - Robert M Barr
- Mecklenburg Radiology Associates, Charlotte, North Carolina
| | - Allan L Brook
- Department of Radiology, Montefiore Medical Center, Bronx
| | - Philip M Meyers
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons
| | - Peter L Munk
- Department of Radiology, Vancouver General Hospital, Vancouver, British Columbia
| | - Kieran J Murphy
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Peter A Rasmussen
- Cerebrovascular Center and Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Pina C Sanelli
- Departments of Radiology and Public Health, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | | | | | - Sean M Tutton
- Department of Radiology, Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin
| | - Gregg H Zoarski
- Department of Neurointerventional Surgery, Christiana Care Health System, Newark, Delaware
| | - Michael D Kuo
- Department of Radiology, University of California, Los Angeles, Medical School, Los Angeles
| | - Steven C Rose
- Department of Radiology, University of California, San Diego, Medical Center, San Diego, California
| | - John F Cardella
- Department of Radiology, Geisinger Health System, Danville, Pennsylvania
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Lindsey SS, Kallmes DF, Opatowsky MJ, Broyles EA, Layton KF. Impact of sham-controlled vertebroplasty trials on referral patterns at two academic medical centers. Proc (Bayl Univ Med Cent) 2013; 26:103-5. [PMID: 23543962 DOI: 10.1080/08998280.2013.11928930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Debate persists regarding the merit of vertebroplasty following publication of blinded vertebroplasty trials in 2009, one of which was the Investigational Vertebroplasty Efficacy and Safety Trial (INVEST). This study was performed to determine whether referring physicians at two academic medical centers were aware of the trial results and to assess if this awareness prompted a change in their treatment of osteoporotic fractures. E-mail surveys were distributed to physicians within the Mayo Clinic and Baylor Health Care System (BHCS). Of 1390 surveys sent, 194 (14%) were returned. Results showed that 92 of 158 respondents (58%) reported familiarity with INVEST; 66 of 92 (72%) agreed that INVEST changed their understanding of vertebroplasty efficacy; and 64 of 92 (70%) agreed that INVEST diminished their enthusiasm to refer patients for vertebroplasty. However, 105 of 159 respondents (66%) felt vertebroplasty was an effective procedure in appropriate patients. Mayo physicians were more likely than BHCS physicians to be aware of INVEST (73% vs 67%, P < .0001), respond that INVEST changed their understanding of the appropriate treatment for osteoporotic compression fractures (79% vs 57%, P = 0.026), view vertebroplasty less favorably (45% vs 21%, P = 0.005), and treat osteoporotic compression fractures with medical therapy/pain management alone (73% vs 48%, P = 0.003). INVEST changed referring physicians' understanding of the role of vertebroplasty and diminished their willingness to refer osteoporotic compression fracture patients; the impact varied by location.
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Affiliation(s)
- Sara S Lindsey
- Department of Radiology, Baylor University Medical Center at Dallas (Lindsey, Opatowsky, Broyles, Layton); and the Mayo Clinic, Rochester, MN (Kallmes)
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Bornemann R, Hanna M, Kabir K, Goost H, Wirtz DC, Pflugmacher R. Continuing conservative care versus crossover to radiofrequency kyphoplasty: a comparative effectiveness study on the treatment of vertebral body fractures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21:930-6. [PMID: 22234722 DOI: 10.1007/s00586-012-2148-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 11/03/2011] [Accepted: 01/02/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy about how to treat vertebral fractures. Conservative care is the default approach. Radiofrequency kyphoplasty uses ultrahigh viscosity cement to restore spinal posture and stabilize the fracture. The aims of this study were to compare radiofrequency kyphoplasty to conservative care and assess the usual algorithm of starting all patients on conservative care for 6 weeks before offering surgery. METHODS Elderly patients with painful osteoporotic vertebral compression fractures were all treated with 6 weeks of conservative care (analgesics, bracing, and physiotherapy). They were then offered the choice of continuing conservative care or crossing over to radiofrequency kyphoplasty, at 6 and 12 weeks. Clinical success was defined as: (1) VAS pain improvement ≥2, (2) final VAS pain ≤5, (3) no functional worsening on ODI. RESULTS After the initial 6 weeks of conservative care, only 1 of 65 patients met the criteria for clinical success, and median VAS improvement was 0. After 12 weeks of conservative care, only 5 of 38 patients met the criteria for clinical success, and median VAS improvement was 1. At the 6-week follow-up after radiofrequency kyphoplasty, 31 of 33 surgery patients met the criteria for clinical success, and median VAS improvement was 5. CONCLUSION For the vast majority of patients with a VAS ≥5, conservative care did not provide meaningful clinical improvement. In contrast, nearly all patients who underwent radiofrequency kyphoplasty had rapid substantial improvement. Surgery was clearly much more effective than conservative care and should be offered to patients much sooner.
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Affiliation(s)
- Rahel Bornemann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freund-Str. 25, 53105 Bonn, Germany.
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Wulff KC, Miller FG, Pearson SD. Can Coverage Be Rescinded When Negative Trial Results Threaten A Popular Procedure? The Ongoing Saga Of Vertebroplasty. Health Aff (Millwood) 2011; 30:2269-76. [DOI: 10.1377/hlthaff.2011.0159] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Katharine Cooper Wulff
- Katharine Cooper Wulff is a Sommer Scholar in the master’s degree program at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Franklin G. Miller
- Franklin G. Miller is a senior faculty member in the Department of Bioethics, National Institutes of Health, in Bethesda, Maryland
| | - Steven D. Pearson
- Steven D. Pearson is a visiting scientist in the Department of Bioethics, National Institutes of Health
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Staples MP, Kallmes DF, Comstock BA, Jarvik JG, Osborne RH, Heagerty PJ, Buchbinder R. Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis. BMJ 2011; 343:d3952. [PMID: 21750078 PMCID: PMC3133975 DOI: 10.1136/bmj.d3952] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine whether vertebroplasty is more effective than placebo for patients with pain of recent onset (≤ 6 weeks) or severe pain (score ≥ 8 on 0-10 numerical rating scale). DESIGN Meta-analysis of combined individual patient level data. SETTING Two multicentred randomised controlled trials of vertebroplasty; one based in Australia, the other in the United States. PARTICIPANTS 209 participants (Australian trial n = 78, US trial n = 131) with at least one radiographically confirmed vertebral compression fracture. 57 (27%) participants had pain of recent onset (vertebroplasty n = 25, placebo n = 32) and 99 (47%) had severe pain at baseline (vertebroplasty n = 50, placebo n = 49). INTERVENTION Percutaneous vertebroplasty versus a placebo procedure. MAIN OUTCOME MEASURE Scores for pain (0-10 scale) and function (modified, 23 item Roland-Morris disability questionnaire) at one month. RESULTS For participants with pain of recent onset, between group differences in mean change scores at one month for pain and disability were 0.1 (95% confidence interval -1.4 to 1.6) and 0.2 (-3.0 to 3.4), respectively. For participants with severe pain at baseline, between group differences for pain and disability scores at one month were 0.3 (-0.8 to 1.5) and 1.4 (-1.2 to 3.9), respectively. At one month those in the vertebroplasty group were more likely to be using opioids. CONCLUSIONS Individual patient data meta-analysis from two blinded trials of vertebroplasty, powered for subgroup analyses, failed to show an advantage of vertebroplasty over placebo for participants with recent onset fracture or severe pain. These results do not support the hypothesis that selected subgroups would benefit from vertebroplasty.
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Affiliation(s)
- Margaret P Staples
- Department of Clinical Epidemiology, Cabrini Hospital, and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
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Miller FG, Kallmes DF. The case of vertebroplasty trials: promoting a culture of evidence-based procedural medicine. Spine (Phila Pa 1976) 2010; 35:2023-6. [PMID: 20938382 PMCID: PMC2964427 DOI: 10.1097/brs.0b013e3181ecd393] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Two independent, randomized controlled trials of vertebroplasty for the relief of pain associated with vertebral fractures demonstrated that this procedure was no better than a sham intervention. Publication of the trial results prompted strong, critical commentaries by practitioners and professional societies. In this article we offer a psychological explanation of this dismissive response to rigorous scientific evidence, which appeals to the “placebo reactions” of physicians when dramatic improvement is noted in patients’ symptoms following administration of invasive procedures. We argue that the story of the response to the vertebroplasty trials underscores the need to develop a culture of evidence-based procedural medicine.
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Bogduk N, MacVicar J, Borowczyk J. The Pain of Vertebral Compression Fractures Can Arise in the Posterior Elements. PAIN MEDICINE 2010; 11:1666-73. [DOI: 10.1111/j.1526-4637.2010.00963.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buchbinder R. EDITORIAL: Case series are no substitute for randomised placebo-controlled trials for determination of treatment efficacy. J Med Imaging Radiat Oncol 2010; 54:299-301. [DOI: 10.1111/j.1754-9485.2010.02174.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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