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Franssen M, Achten J, Appelbe D, Costa ML, Dutton S, Mason J, Gould J, Gray A, Rangan A, Sheehan W, Singh H, Gwilym SE. A protocol for the conduct of a multicentre, prospective, randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures. Bone Jt Open 2024; 5:343-349. [PMID: 38643977 PMCID: PMC11033090 DOI: 10.1302/2633-1462.54.bjo-2023-0151.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
Aims Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures. Methods The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive. Discussion The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England - Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024.
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Affiliation(s)
- Marloes Franssen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Juul Achten
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Susan Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny Gould
- Patient and Public Representative, Abingdon, UK
| | - Andrew Gray
- James Cook University Hospital, Middlesbrough, UK
| | - Amar Rangan
- James Cook University Hospital, Middlesbrough, UK
| | - Warren Sheehan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Harvinder Singh
- University Hospital of Leicester, NHS Foundation Trust, Leicester, UK
| | - Stephen E. Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
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Barber VS, Calvert C, Appelbe D, Sprange K, Nollett C, Tanner S, Richards DB. Current usage of explainer animations in trials: a survey of the UKCRC registered clinical trial units in the UK. Trials 2024; 25:224. [PMID: 38549126 PMCID: PMC10976673 DOI: 10.1186/s13063-024-08060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/15/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Explainer animations are a means to communicate aspects of clinical trials to participants in a more engaging and accessible way. Delivered well these have the potential to enhance recruitment and retention. The range of media technology used to deliver this material is expanding rapidly but is highly fragmented. Usage of explainer animations across the UK is unknown, the aim of this research was to determine current usage across the 52 registered UK Clinical Research Collaboration (UKCRC) Clinical Trials Units (CTUs) to understand the current landscape and any barriers that could be preventing wider uptake of this functionality. METHODS A survey link was emailed to all UKCRC CTU Directors and Trial Management Leads to ascertain current usage of explainer animations within their CTU. The survey ran between 01 February 2023 and 07 March 2023. RESULTS Responses were received from 35 CTUs-representing a response rate of 67%. 24 CTUs (69%) reported that they had created/used at least one explainer animation within their unit, although the usage, cost, length and production activities varied among the units. CONCLUSIONS The survey showed that a high proportion of the UKCRC CTUs have used explainer animations to provide information to participants about clinical studies. For those not using the technology yet, the most common reasons cited were a lack of expertise, lack of resources and costs to produce them. One of the desired outcomes of this project is the creation of a free-to-use library of animations to encourage wider uptake and avoid duplication.
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Affiliation(s)
- Vicki S Barber
- Oxford Clinical Trials Research Unit (OCTRU), University of Oxford, Oxford, UK.
| | - Clare Calvert
- Oxford Clinical Trials Research Unit (OCTRU), University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Clinical Trials Research Unit (OCTRU), University of Oxford, Oxford, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Claire Nollett
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Samantha Tanner
- Oxford Clinical Trials Research Unit (OCTRU), University of Oxford, Oxford, UK
| | - Duncan B Richards
- Oxford Clinical Trials Research Unit (OCTRU), University of Oxford, Oxford, UK
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Abhishek A, Peckham N, Pade C, Gibbons JM, Cureton L, Francis A, Barber V, Williams JAE, Appelbe D, Eldridge L, Julier P, Altmann DM, Bluett J, Brooks T, Coates LC, Rombach I, Semper A, Otter A, Valdes AM, Nguyen-Van-Tam JS, Williams HC, Boyton RJ, McKnight Á, Cook JA. Effect of a 2-week interruption in methotrexate treatment on COVID-19 vaccine response in people with immune-mediated inflammatory diseases (VROOM study): a randomised, open label, superiority trial. Lancet Rheumatol 2024; 6:e92-e104. [PMID: 38267107 DOI: 10.1016/s2665-9913(23)00298-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Methotrexate is the first-line treatment for immune-mediated inflammatory diseases and reduces vaccine-induced immunity. We evaluated if a 2-week interruption of methotrexate treatment immediately after COVID-19 booster vaccination improved antibody response against the S1 receptor binding domain (S1-RBD) of the SARS-CoV-2 spike protein and live SARS-CoV-2 neutralisation compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. METHOD We did a multicentre, open-label, parallel-group, randomised, superiority trial in secondary-care rheumatology and dermatology clinics in 26 hospitals in the UK. Adults (aged ≥18 years) with immune-mediated inflammatory diseases taking methotrexate (≤25 mg per week) for at least 3 months, who had received two primary vaccine doses from the UK COVID-19 vaccination programme were eligible. Participants were randomly assigned (1:1) using a centralised validated computer program, to temporarily suspend methotrexate treatment for 2 weeks immediately after COVID-19 booster vaccination or continue treatment as usual. The primary outcome was S1-RBD antibody titres 4 weeks after COVID-19 booster vaccination and was assessed masked to group assignment. All randomly assigned patients were included in primary and safety analyses. This trial is registered with ISRCTN, ISRCTN11442263; following a pre-planned interim analysis, recruitment was stopped early. FINDING Between Sept 30, 2021, and March 7, 2022, we screened 685 individuals, of whom 383 were randomly assigned: to either suspend methotrexate (n=191; mean age 58·8 years [SD 12·5], 118 [62%] women and 73 [38%] men) or to continue methotrexate (n=192; mean age 59·3 years [11·9], 117 [61%] women and 75 [39%] men). At 4 weeks, the geometric mean S1-RBD antibody titre was 25 413 U/mL (95% CI 22 227-29 056) in the suspend methotrexate group and 12 326 U/mL (10 538-14 418) in the continue methotrexate group with a geometric mean ratio (GMR) of 2·08 (95% CI 1·59-2·70; p<0·0001). No intervention-related serious adverse events occurred. INTERPRETATION 2-week interruption of methotrexate treatment in people with immune-mediated inflammatory diseases enhanced antibody responses after COVID-19 booster vaccination that were sustained at 12 weeks and 26 weeks. There was a temporary increase in inflammatory disease flares, mostly self-managed. The choice to suspend methotrexate should be individualised based on disease status and vulnerability to severe outcomes from COVID-19. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Corinna Pade
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joseph M Gibbons
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Jennifer A E Williams
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Patrick Julier
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Daniel M Altmann
- Department of Inflammation and Immunology, Imperial College London, London, UK
| | - James Bluett
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK; Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | | | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Biomedical Research Centre, Oxford, UK
| | - Ines Rombach
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, UK
| | | | | | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK; Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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Achten J, Appelbe D, Spoors L, Peckham N, Kandiyali R, Mason J, Ferguson D, Wright J, Wilson N, Preston J, Moscrop A, Costa M, Perry DC. Protocol for Surgery or Cast of the EpicoNdyle in Children's Elbows (SCIENCE). Bone Jt Open 2024; 5:69-77. [PMID: 38269598 PMCID: PMC10809059 DOI: 10.1302/2633-1462.51.bjo-2023-0127.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Aims The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children's Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children's Elbows (SCIENCE) trial. Methods Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment. Outcomes At six weeks, and three, six, and 12 months, data on function, pain, sports/music participation, QoL, immobilization, and analgesia will be collected. These will also be repeated annually until the child reaches the age of 16 years. Four weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the PROMIS upper limb score at 12 months post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardians. The NHS number of participants will be stored to enable future data linkage to sources of routinely collected data (i.e. Hospital Episode Statistics).
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Affiliation(s)
- Juul Achten
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Louise Spoors
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - James Mason
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - David Ferguson
- South Tees Hospitals NHS Foundation Trust, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jennifer Preston
- University of Liverpool, Institute of Translational Medicine, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
- Alder Hey Children’s Hospital, Liverpool, UK
| | | | - Matthew Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel C. Perry
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
- University of Liverpool, Institute of Translational Medicine, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
- Alder Hey Children’s Hospital, Liverpool, UK
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Howard A, Woods A, Rombach I, Achten J, Appelbe D, Athwal A, Jones E, Draper K, Gwilym S. SPiRIT study protocol (Shoulder Pain: Randomised trial of Injectable Treatments): a randomised feasibility and pilot study of autologous protein solution (APS) vs corticosteroids for treating subacromial shoulder pain. Pilot Feasibility Stud 2024; 10:9. [PMID: 38233904 DOI: 10.1186/s40814-023-01425-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/19/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The management of subacromial shoulder pain represents a significant challenge and is typically managed through either physiotherapy, joint injection or surgical intervention. Recent surgical trials have questioned the efficacy and there is a need to improve the evidence base for the non-surgical management of this condition. The study aims to provide evidence of the feasibility of conducting a randomised controlled trial to compare the efficacy of autologous protein solution (APS) against the current standard of care, corticosteroid injection (CSI) for subacromial shoulder pain. Autologous protein solution (APS) is a blood-derived biological injection which has been shown to have anti-inflammatory effects. METHODS A parallel-group two-arm randomised control trial will be conducted, comparing APS and CSI for shoulder pain. Fifty patients will be recruited. Feasibility will be assessed by examination of the conversion rate of eligible participants to the total number of participants recruited, whether it is possible to collect the appropriate outcome measures and the levels of retention/data compliance at follow-up dates. DISCUSSION CSI is the mainstay of conservative management of subacromial shoulder pain. Trials and systematic reviews have reported differing conclusions, but the consensus view is that any benefits seen from CSI use are most likely to be short-term and there remains a significant number of patients who go on to have surgical intervention despite CSI. Biological injections, such as APS are being increasingly used, in the anticipation they may offer improved longer lasting outcomes for shoulder pain. However, the evidence to demonstrate the comparative efficacy of CSI versus APS does not currently exist. If feasible, a fully powered study will offer clarity to the treatment pathway of thousands of patients each year with subacromial pain. TRIAL REGISTRATION The study is funded by the National Institute for Health Research-Research for Patient Benefit, NIHR 201473, Trial Registration Number (ISRCTN12536844: SPiRIT. Shoulder pain: randomised trial of injectable treatments-date of Registration 15/9/2021). Protocol Version V1.0_30Jul2021. IRAS Project ID: 294,982.
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Affiliation(s)
- A Howard
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England.
- University of Oxford, Joint Research Office, 1St Floor, Boundary Brook House Churchill Drive, Headington, OX3 7GB, England.
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK.
| | - A Woods
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - I Rombach
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - J Achten
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - D Appelbe
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - A Athwal
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - E Jones
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - K Draper
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
| | - S Gwilym
- Oxford Clinical Trials Research Unit, Oxford Trauma, Kadoorie Centre, NDORMS, University of Oxford, Oxford, England
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Mitchell EJ, Appelbe D, Bravery A, Culliford L, Evans H, Farrin AJ, Gillies K, Hood K, Love SB, Sydes MR, Williamson PR, Wakefield N. e-Consent in UK academic-led clinical trials: current practice, challenges and the need for more evidence. Trials 2023; 24:657. [PMID: 37817277 PMCID: PMC10565982 DOI: 10.1186/s13063-023-07656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/15/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, in-person healthcare visits were reduced. Consequently, trial teams needed to consider implementing remote methods for conducting clinical trials, including e-Consent. Although some clinical trials may have implemented e-Consent prior to the pandemic, anecdotes of uptake for this method increased within academic-led trials. When the increased use of this process emerged, representatives from several large academic clinical trial groups within the UK collaborated to discuss ways in which trialists can learn from one another when implementing e-Consent. METHODS A survey of UKCRC-registered Clinical Trials Units (CTUs) was undertaken in April-June 2021 to understand the implementation of and their views on the use of e-Consent and experiences from the perspectives of systems programmers and quality assurance staff on the use of e-Consent. CTUs not using e-Consent were asked to provide any reasons/barriers (including no suitable trials) and any plans for implementing it in the future. Two events for trialists and patient and public involvement (PPI) representatives were then held to disseminate findings, foster discussion, share experiences and aid in the identification of areas that the academic CTU community felt required more research. RESULTS Thirty-four (64%) of 53 CTUs responded to the survey, with good geographical representation across the UK. Twenty-one (62%) of the responding CTUs had implemented e-Consent in at least one of their trials, across different types of trials, including CTIMPs (Clinical Trial of Investigational Medicinal Product), ATIMPs (Advanced Therapy Medicinal Products) and non-CTIMPs. One hundred ninety-seven participants attended the two workshops for wide-ranging discussions. CONCLUSION e-Consent is increasingly used in academic-led trials, yet uncertainties remain amongst trialists, patients and members of the public. Uncertainties include a lack of formal, practical guidance and a lack of evidence to demonstrate optimal or appropriate methods to use. We strongly encourage trialists to continue to share their own experiences of the implementation of e-Consent.
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Affiliation(s)
- E J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, Applied Health Research Building, University Park, Nottingham, NG7 2RD, UK.
| | - D Appelbe
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - A Bravery
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - L Culliford
- Bristol Trials Centre, University of Bristol, Bristol Medical School, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - H Evans
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9NL, UK
| | - A J Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9NL, UK
| | - K Gillies
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - K Hood
- Centre for Trial Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - S B Love
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, 90 High Holborn, London, WC1V 6LJ, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, 90 High Holborn, London, WC1V 6LJ, UK
- BHF Data Science Centre, Health Data Research UK, 215 Euston Road, London, NW1 2BE, UK
| | - P R Williamson
- MRC-NIHR Trials Methodology Research Partnership, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - N Wakefield
- Nottingham Clinical Trials Unit, School of Medicine, Applied Health Research Building, University Park, Nottingham, NG7 2RD, UK
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Tabu I, Goh EL, Appelbe D, Parsons N, Lekamwasam S, Lee JK, Amphansap T, Pandey D, Costa M. Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia. Bone Jt Open 2023; 4:676-681. [PMID: 37666496 PMCID: PMC10477024 DOI: 10.1302/2633-1462.49.bjo-2023-0075.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
Aims The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines). Methods The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up. Results Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals. Conclusion This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system.
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Affiliation(s)
- Irewin Tabu
- Department of Orthopedics, University of the Philippines Manila, Manila, Philippines
- Institute on Aging, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - En L. Goh
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Sarath Lekamwasam
- University of Ruhuna, Matara, Sri Lanka
- Department of Medicine, University of Ruhuna, Matara, Sri Lanka
| | | | | | | | - Matthew Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - On behalf of FERMAT collaborators and the Global Fragility Fracture Network Hip Fracture Audit Special Interest Group
- Department of Orthopedics, University of the Philippines Manila, Manila, Philippines
- Institute on Aging, National Institutes of Health, University of the Philippines, Manila, Philippines
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- University of Warwick Faculty of Medicine, Coventry, UK
- University of Ruhuna, Matara, Sri Lanka
- Department of Medicine, University of Ruhuna, Matara, Sri Lanka
- Beacon Hospital, Petaling Jaya, Malaysia
- Police General Hospital, Bangkok, Thailand
- National Trauma Center, Kathmandu, Nepal
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Forde C, Costa ML, Cook JA, Tutton E, Appelbe D, Franssen M, Barker R, Keene DJ. Physiotherapy Rehabilitation Post Patellar Dislocation (PRePPeD)-protocol for an external pilot randomised controlled trial and qualitative study comparing supervised versus self-managed rehabilitation for people after acute patellar dislocation. Pilot Feasibility Stud 2023; 9:119. [PMID: 37430340 DOI: 10.1186/s40814-023-01349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Patellar dislocations mainly affect adolescents and young adults. After this injury, patients are usually referred to physiotherapy for exercise-based rehabilitation. Currently, limited high-quality evidence exists to guide rehabilitation practice and treatment outcomes vary. A full-scale trial comparing different rehabilitation approaches would provide high-quality evidence to inform rehabilitation practice. Whether this full-scale trial is feasible is uncertain: the only previous trial that compared exercise-based programmes in this patient population had high loss to follow-up. This study aims to assess the feasibility of conducting a future full-scale trial comparing the clinical and cost-effectiveness of two different rehabilitation approaches for people with an acute patellar dislocation. METHODS Two-arm parallel external pilot randomised controlled trial and qualitative study. We aim to recruit at least 50 participants aged ≥ 14 years with an acute first-time or recurrent patellar dislocation from at least three English National Health Service hospitals. Participants will be randomised 1:1 to supervised rehabilitation (four to six, one-to-one, physiotherapy sessions of advice and prescription of tailored progressive home exercise over a maximum of 6 months) or self-managed rehabilitation (one physiotherapy session of self-management advice, exercise, and provision of self-management materials). Pilot objectives are (1) willingness to be randomised, (2) recruitment rate, (3) retention, (4) intervention adherence, and (5) intervention and follow-up method acceptability to participants assessed through one-to-one semi-structured interviews (maximum 20 participants). Follow-up data will be collected 3, 6, and 9 months after randomisation. Quantitative pilot and clinical outcomes will be numerically summarised, with 95% confidence intervals generated for the pilot outcomes using Wilson's and exact Poisson methods as appropriate. DISCUSSION This study will assess the feasibility of conducting a full-scale trial comparing supervised versus self-managed rehabilitation for people after acute first-time or recurrent patellar dislocation. This full-scale trial's results would provide high-quality evidence to guide rehabilitation provision for patients with this injury. TRIAL REGISTRATION ISRCTN registry ISRCTN14235231 . Registered on 09 August 2022.
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Affiliation(s)
- Colin Forde
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marloes Franssen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - David J Keene
- Exeter Medical School, University of Exeter, Exeter, UK
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Abhishek A, Boyton RJ, Peckham N, McKnight Á, Coates LC, Bluett J, Barber V, Cureton L, Francis A, Appelbe D, Eldridge L, Julier P, Valdes AM, Brooks T, Rombach I, Altmann DM, Nguyen-Van-Tam JS, Williams HC, Cook JA. Effect of a 2-week interruption in methotrexate treatment versus continued treatment on COVID-19 booster vaccine immunity in adults with inflammatory conditions (VROOM study): a randomised, open label, superiority trial. Lancet Respir Med 2022; 10:840-850. [PMID: 35772416 PMCID: PMC9236568 DOI: 10.1016/s2213-2600(22)00186-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Immunosuppressive treatments inhibit vaccine-induced immunity against SARS-CoV-2. We evaluated whether a 2-week interruption of methotrexate treatment immediately after the COVID-19 vaccine booster improved antibody responses against the S1 receptor-binding domain (S1-RBD) of the SARS-CoV-2 spike protein compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. METHODS We did an open-label, prospective, two-arm, parallel-group, multicentre, randomised, controlled, superiority trial in 26 hospitals in the UK. We recruited adults from rheumatology and dermatology clinics who had been diagnosed with an immune-mediated inflammatory disease (eg, rheumatoid arthritis, psoriasis with or without arthritis, axial spondyloarthritis, atopic dermatitis, polymyalgia rheumatica, and systemic lupus erythematosus) and who were taking low-dose weekly methotrexate (≤25 mg per week) for at least 3 months. Participants also had to have received two primary vaccine doses from the UK COVID-19 vaccination programme. We randomly assigned the participants (1:1), using a centralised validated computer randomisation program, to suspend methotrexate treatment for 2 weeks immediately after their COVID-19 booster (suspend methotrexate group) or to continue treatment as usual (continue methotrexate group). Participants, investigators, clinical research staff, and data analysts were unmasked, while researchers doing the laboratory analyses were masked to group assignment. The primary outcome was S1-RBD antibody titres 4 weeks after receiving the COVID-19 booster vaccine dose, assessed in the intention-to-treat population. This trial is registered with ISRCT, ISRCTN11442263; following the pre-planned interim analysis, recruitment was stopped early. FINDINGS Between Sept 30, 2021 and March 3, 2022, we recruited 340 participants, of whom 254 were included in the interim analysis and had been randomly assigned to one of the two groups: 127 in the continue methotrexate group and 127 in the suspend methotrexate group. Their mean age was 59·1 years, 155 (61%) were female, 130 (51%) had rheumatoid arthritis, and 86 (34%) had psoriasis with or without arthritis. After 4 weeks, the geometric mean S1-RBD antibody titre was 22 750 U/mL (95% CI 19 314-26 796) in the suspend methotrexate group and 10 798 U/mL (8970-12 997) in the continue methotrexate group, with a geometric mean ratio (GMR) of 2·19 (95% CI 1·57-3·04; p<0·0001; mixed-effects model). The increased antibody response in the suspend methotrexate group was consistent across methotrexate dose, administration route, type of immune-mediated inflammatory disease, age, primary vaccination platform, and history of SARS-CoV-2 infection. There were no intervention-related serious adverse events. INTERPRETATION A 2-week interruption of methotrexate treatment for people with immune-mediated inflammatory diseases resulted in enhanced boosting of antibody responses after COVID-19 vaccination. This intervention is simple, low-cost, and easy to implement, and could potentially translate to increased vaccine efficacy and duration of protection for susceptible groups. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK; Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, UK
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Biomedical Research Centre, Oxford, UK
| | - James Bluett
- National Institute of Health and Care Research, Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Patrick Julier
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | | | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Daniel M Altmann
- Department of Inflammation and Immunology, Imperial College London, London, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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10
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Moe-Byrne T, Knapp P, Perry D, Achten J, Spoors L, Appelbe D, Roche J, Martin-Kerry JM, Sheridan R, Higgins S. Does digital, multimedia information increase recruitment and retention in a children's wrist fracture treatment trial, and what do people think of it? A randomised controlled Study Within A Trial (SWAT). BMJ Open 2022; 12:e057508. [PMID: 35831055 PMCID: PMC9280884 DOI: 10.1136/bmjopen-2021-057508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To evaluate digital, multimedia information (MMI) for its effects on trial recruitment, retention, decisions about participation and acceptability by patients, compared with printed information. DESIGN Study Within A Trial using random cluster allocation within the Forearm Fracture Recovery in Children Evaluation (FORCE) study. SETTING Emergency departments in 23 UK hospitals. PARTICIPANTS 1409 children aged 4-16 years attending with a torus (buckle) fracture, and their parents/guardian. Children's mean age was 9.2 years, 41.0% were female, 77.4% were ethnically White and 90.0% spoke English as a first language. INTERVENTIONS Participants and their parents/guardian received trial information either via multimedia, including animated videos, talking head videos and text (revised for readability and age appropriateness when needed) on tablet computer (MMI group; n=681), or printed participant information sheet (PIS group; n=728). OUTCOME MEASURES Primary outcome was recruitment rate to FORCE. Secondary outcomes were Decision-Making Questionnaire (nine Likert items, analysed summatively and individually), three 'free text' questions (deriving subjective evaluations) and trial retention. RESULTS MMI produced a small, not statistically significant increase in recruitment: 475 (69.8%) participants were recruited from the MMI group; 484 (66.5%) from the PIS group (OR=1.35; 95% CI 0.76 to 2.40, p=0.31). A total of 324 (23.0%) questionnaires were returned and analysed. There was no difference in total Decision-Making Questionnaire scores: adjusted mean difference 0.05 (95% CI -1.23 to 1.32, p=0.94). The MMI group was more likely to report the information 'very easy' to understand (89; 57.8% vs 67; 39.4%; Z=2.60, p=0.01) and identify information that was explained well (96; 62.3% vs 71; 41.8%). Almost all FORCE recruits were retained at the 6 weeks' timepoint and there was no difference in retention rate between the information groups: MMI (473; 99.6%); PIS (481; 99.4%). CONCLUSIONS MMI did not increase recruitment or retention in the FORCE trial, but participants rated multimedia as easier to understand and were more likely to evaluate it positively. TRIAL REGISTRATION NUMBER ISRCTN73136092 and ISRCTN13955395.
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Affiliation(s)
| | - Peter Knapp
- Health Sciences and the Hull York Medical School, University of York, York, UK
| | | | | | - Louise Spoors
- NDORMS, University of Oxford, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jenny Roche
- Health Sciences, University of York, York, UK
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11
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Perry DC, Achten J, Knight R, Appelbe D, Dutton SJ, Dritsaki M, Mason JM, Roland DT, Messahel S, Widnall J, Costa ML. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet 2022; 400:39-47. [PMID: 35780790 DOI: 10.1016/s0140-6736(22)01015-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/27/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol. METHODS In this randomised controlled equivalence trial we included 965 children (aged 4-15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395. FINDINGS Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was -0·10 (95% CI -0·37 to 0·17) and-0·06 (95% CI -0·34 to 0·21) in the per-protocol population. INTERPRETATION This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Daniel C Perry
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Alder Hey Children's Foundation Trust, Liverpool, UK.
| | - Juul Achten
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - James M Mason
- Centre for Health Economics, Warwick, University of Warwick, Coventry, UK
| | - Damian T Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK; SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | | | - James Widnall
- Alder Hey Children's Foundation Trust, Liverpool, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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12
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Dickenson E, Griffin XL, Achten J, Mironov K, O'Connor H, Parsons N, Murphy M, Wyse M, Mason J, Appelbe D, Athwal A, Griffin D. Randomised controlled trial comparing intraoperative cell salvage and autotransfusion with standard care in the treatment of hip fractures: a protocol for the WHITE 9 study. BMJ Open 2022; 12:e062338. [PMID: 35676006 PMCID: PMC9185657 DOI: 10.1136/bmjopen-2022-062338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION People who sustain a hip fracture are typically elderly, frail and require urgent surgery. Hip fracture and the urgent surgery is associated with acute blood loss, compounding patients' pre-existing comorbidities including anaemia. Approximately 30% of patients require a donor blood transfusion in the perioperative period. Donor blood transfusions are associated with increased rates of infections, allergic reactions and longer lengths of stay. Furthermore, there is a substantial cost associated with the use of donor blood. Cell salvage and autotransfusion is a technique that recovers, washes and transfuses blood lost during surgery back to the patient. The objective of this study is to determine the clinical and cost effectiveness of intraoperative cell salvage, compared with standard care, in improving health related quality-of-life of patients undergoing hip fracture surgery. METHODS AND ANALYSIS Multicentre, parallel group, two-arm, randomised controlled trial. Patients aged 60 years and older with a hip fracture treated with surgery are eligible. Participants will be randomly allocated on a 1:1 basis to either undergo cell salvage and autotransfusion or they will follow the standard care pathway. Otherwise, all care will be in accordance with the National Institute for Health and Care Excellence guidance. A minimum of 1128 patients will be recruited to obtain 90% power to detect a 0.075-point difference in the primary endpoint: EuroQol-5D-5L HRQoL at 4 months post injury. Secondary outcomes will include complications, postoperative delirium, residential status, mobility, allogenic blood use, mortality and resource use. ETHICS AND DISSEMINATION NHS ethical approval was provided on 14 August 2019 (19/WA/0197) and the trial registered (ISRCTN15945622). After the conclusion of this trial, a manuscript will be prepared for peer-review publication. Results will be disseminated in lay form to participants and the public. TRIAL REGISTRATION NUMBER ISRCTN15945622.
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Affiliation(s)
| | - Xavier Luke Griffin
- Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Honorary Trauma and Orthopaedic Surgeon, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Juul Achten
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Katy Mironov
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Heather O'Connor
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Mike Murphy
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - Matthew Wyse
- Consultant Anaesthetist, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Duncan Appelbe
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amrita Athwal
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Damian Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
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13
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Abhishek A, Boyton RJ, McKnight Á, Coates L, Bluett J, Barber VS, Cureton L, Francis A, Appelbe D, Eldridge L, Julier P, Peckham N, Valdes AM, Rombach I, Altmann DM, Nguyen-Van-Tam J, Williams HC, Cook JA. Effects of temporarily suspending low-dose methotrexate treatment for 2 weeks after SARS-CoV-2 vaccine booster on vaccine response in immunosuppressed adults with inflammatory conditions: protocol for a multicentre randomised controlled trial and nested mechanistic substudy (Vaccine Response On/Off Methotrexate (VROOM) study). BMJ Open 2022; 12:e062599. [PMID: 35504634 PMCID: PMC9066090 DOI: 10.1136/bmjopen-2022-062599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION It is unknown if a temporary break in long-term immune-suppressive treatment after vaccination against COVID-19 improves vaccine response. The objective of this study was to evaluate if a 2-week interruption in low-dose weekly methotrexate treatment after SARS-CoV-2 vaccine boosters enhances the immune response compared with continuing treatment in adults with autoimmune inflammatory conditions. METHODS AND ANALYSIS An open-label, pragmatic, prospective, parallel group, randomised controlled superiority trial with internal feasibility assessment and nested mechanistic substudy will be conducted in rheumatology and dermatology clinics in approximately 25 UK hospitals. The sample size is 560, randomised 1:1 to intervention and usual care arms. The main outcome measure is anti-spike receptor-binding domain (RBD) antibody level, collected at prebooster (baseline), 4 weeks (primary outcome) and 12 weeks (secondary outcome) post booster vaccination. Other secondary outcome measures are patient global assessments of disease activity, disease flares and their treatment, EuroQol 5- dimention 5-level (EQ-5D-5L), self-reported adherence with advice to interrupt or continue methotrexate, neutralising antibody titre against SARS-CoV-2 (mechanistic substudy) and oral methotrexate biochemical adherence (mechanistic substudy). Analysis of B-cell memory and T-cell responses at baseline and weeks 4 and 12 will be investigated subject to obtaining additional funding. The principal analysis will be performed on the groups as randomised (ie, intention to treat). The difference between the study arms in anti-spike RBD antibody level will be estimated using mixed effects model, allowing for repeated measures clustered within participants. The models will be adjusted for randomisation factors and prior SARS-CoV-2 infection status. ETHICS AND DISSEMINATION This study was approved by the Leeds West Research Ethics Committee and Health Research Authority (REC reference: 21/HRA/3483, IRAS 303827). Participants will be required to give written informed consent before taking part in the trial. Dissemination will be via peer review publications, newsletters and conferences. Results will be communicated to policymakers. TRIAL REGISTRATION NUMBER ISRCTN11442263.
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Affiliation(s)
| | - R J Boyton
- Department of Infectious Diseases, Imperial College London, London, UK
- Lung Division, Royal Brompton and Harefield Hospitals, London, London
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | | | - James Bluett
- Manchester Academic Health Science Centre, Manchester, UK
- The University of Manchester, Manchester, UK
| | - Vicki S Barber
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Lucy Cureton
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Anne Francis
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Duncan Appelbe
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Lucy Eldridge
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Patrick Julier
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Nicholas Peckham
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - Ines Rombach
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Jonathan Alistair Cook
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
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14
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Perry DC, Arch B, Appelbe D, Francis P, Craven J, Monsell FP, Williamson P, Knight M. The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain. Bone Joint J 2022; 104-B:519-528. [PMID: 35360942 PMCID: PMC9020520 DOI: 10.1302/0301-620x.104b4.bjj-2021-1709.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). METHODS This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. RESULTS A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define 'at risk'. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. CONCLUSION The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519-528.
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Affiliation(s)
- Daniel C Perry
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.,Trauma and Orthopaedics Department, Alder Hey Children's Hospital, Liverpool, UK.,Kadoorie Centre, Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Oxford, UK
| | - Barbara Arch
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Duncan Appelbe
- Kadoorie Centre, Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Oxford, UK
| | - Priya Francis
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Joanna Craven
- North West School of Surgery, Health Education England, Liverpool, UK
| | | | - Paula Williamson
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Perry DC, Arch B, Appelbe D, Francis P, Craven J, Monsell FP, Williamson P, Knight M. The British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain. Bone Joint J 2022; 104-B:510-518. [PMID: 35360941 PMCID: PMC9020518 DOI: 10.1302/0301-620x.104b4.bjj-2021-1708.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Aims The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip. Methods This was an anonymized comprehensive cohort study of Perthes’ disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children’s hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results Overall, 371 children (396 hips) were newly affected by Perthes’ disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years. Conclusion Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510–518.
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Affiliation(s)
- Daniel C Perry
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.,Trauma and Orthopaedics Department, Alder Hey Children's Hospital, Liverpool, UK.,Kadoorie Centre, Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Oxford, UK
| | - Barbara Arch
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Duncan Appelbe
- Kadoorie Centre, Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Oxford, UK
| | - Priya Francis
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Joanna Craven
- North West Trauma and Orthopaedic Surgery (Cheshire and Merseyside), Health Education England, Liverpool, UK
| | | | - Paula Williamson
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Keene DJ, Srikesavan C, Achten J, Tutton E, Dutton SJ, Marian IR, Grant R, Gould J, Herbert K, Athwal A, Appelbe D, Lamb SE, Costa ML. Flexibility and resistance exercises versus usual care for improving pain and function after distal radius fracture in adults aged 50 years or over: protocol for the WISE randomised multicentre feasibility trial. Pilot Feasibility Stud 2022; 8:55. [PMID: 35256000 PMCID: PMC8898994 DOI: 10.1186/s40814-022-01011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background Distal radius fractures represent about 1 in 5 of all fractures treated in UK hospitals. Most distal radius fractures occur in women aged 50 years or over after a fall. Distal radius fractures are managed using splints or casting, some are also treated with surgical fixation. Patients often experience long-term muscle weakness of the hand and arm that may impact their ability to do daily activities such as personal hygiene, routine household chores and food preparation. We propose a structured and tailored flexibility and resistance exercise programme for the hand and arm supplemented with behaviour change strategies to help perform daily exercise. The main aim of our study is to assess the feasibility of conducting a definitive randomised controlled trial. Methods This study is a multicentre, parallel-group individually randomised feasibility trial. We will recruit a minimum of 72 adults aged 50 years or over with distal radius fracture treated surgically or non-surgically from at least three UK National Health Service (NHS) hospitals. They will be randomised 1:1:1 to receive usual care, usual care and independent exercise with a single therapy session or usual care and supervised exercise with three therapy sessions over 12 weeks. Our primary feasibility objectives are (1) patient engagement assessed by recruitment, (2) acceptability of the interventions assessed by adherence and patient and clinician experience and (3) retention of participants in the trial. Outcome measures will be assessed at baseline, 3 months and at 6 months after randomisation. A qualitative sub-study will explore the experiences of the trial participants and therapists delivering the exercises. Discussion A definitive trial will be considered feasible without major modifications if our progression criteria are met. If successful, the findings will inform the design of a future definitive RCT to evaluate the clinical and cost-effectiveness of the WISE exercise programme. Trial registration ISRCTN12290145.
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Lobban F, Akers N, Appelbe D, Iraci Capuccinello R, Chapman L, Collinge L, Dodd S, Flowers S, Hollingsworth B, Honary M, Johnson S, Jones SH, Mateus C, Mezes B, Murray E, Panagaki K, Rainford N, Robinson H, Rosala-Hallas A, Sellwood W, Walker A, Williamson PR. A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT. Health Technol Assess 2021; 24:1-142. [PMID: 32608353 DOI: 10.3310/hta24320] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution. OBJECTIVE The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT). DESIGN AND SETTING This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks. PARTICIPANTS A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited. INTERVENTION REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages. MAIN OUTCOME MEASURE The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items. RESULTS Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported. LIMITATIONS The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random. CONCLUSIONS An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only. FUTURE WORK Further research in improving the effectiveness of online carer support interventions is required. TRIAL REGISTRATION Current Controlled Trials ISRCTN72019945. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona Lobban
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nadia Akers
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Duncan Appelbe
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool (a member of Liverpool Health Partners), Liverpool, UK
| | | | - Lesley Chapman
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lizzi Collinge
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Susanna Dodd
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool (a member of Liverpool Health Partners), Liverpool, UK
| | - Sue Flowers
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Bruce Hollingsworth
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Mahsa Honary
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Steven H Jones
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Ceu Mateus
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Barbara Mezes
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Katerina Panagaki
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Naomi Rainford
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool (a member of Liverpool Health Partners), Liverpool, UK
| | - Heather Robinson
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Anna Rosala-Hallas
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool (a member of Liverpool Health Partners), Liverpool, UK
| | - William Sellwood
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Andrew Walker
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Paula R Williamson
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool (a member of Liverpool Health Partners), Liverpool, UK
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Bretherton CP, Claireaux HA, Achten J, Athwal A, Dutton SJ, Peckham N, Petrou S, Kearney RS, Appelbe D, Griffin XL. Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture. BMC Musculoskelet Disord 2021; 22:672. [PMID: 34372803 PMCID: PMC8353856 DOI: 10.1186/s12891-021-04560-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 01/26/2023] Open
Abstract
Background Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture. Methods Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery (‘early weight-bearing’ group) or to not weight-bear for a further four weeks (‘delayed weight -bearing’ group). All other treatment will be as per the guidance of the treating clinician. Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation. A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options. Discussion The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures. Trial registration ISRCTN12883981, Registered 02 December 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04560-7.
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Affiliation(s)
- C P Bretherton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - H A Claireaux
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J Achten
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A Athwal
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - N Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S Petrou
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - R S Kearney
- Department of Musculoskeletal Rehabilitation, University of Warwick, Coventry, UK
| | - D Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - X L Griffin
- Trauma and Orthopaedic Surgery, Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Perry DC, Arch B, Appelbe D, Francis P, Spowart C, Knight M. A protocol for a nationwide multicentre, prospective surveillance cohort and nested-consented cohort to determine the incidence and clinical outcomes of slipped capital femoral epiphysis. Bone Jt Open 2020; 1:35-40. [PMID: 33215105 PMCID: PMC7659633 DOI: 10.1302/2633-1462.13.bjo-2020-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aims Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge. Methods The study is an anonymized nationwide comprehensive cohort study with nested consented within the mechanism of the British Orthopaedic Surgery Surveillance (BOSS) Study. All relevant hospitals treating SCFE in England, Scotland, and Wales will contribute anonymized case details. Potential missing cases will be cross-checked against two independent external sources of data (the national administrative data and independent trainee data). Patients will be invited to enrich the data collected by supplementing anonymized case data with patient-reported outcome measures. In line with recommendations of the IDEAL Collaboration, the study will primarily seek to determine incidence, describe case mix and variations in surgical interventions, and explore the relationships between baseline factors (patients and types of interventions) and two-year outcomes. Discussion This is the first disease to be investigated using the BOSS Study infrastructure. It provides a robust method to determine the disease frequency, and a large unbiased sample of cases from which treatment strategies can be investigated. It may form the basis for definitive robust intervention studies or, where these are demonstrated not to be feasible, this may be the most robust cohort study.
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Affiliation(s)
- Daniel C Perry
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Barbara Arch
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Duncan Appelbe
- NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Priya Francis
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Catherine Spowart
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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20
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Perry DC, Arch B, Appelbe D, Francis P, Spowart C, Knight M. The BOSS Study. Determining the incidence and clinical outcomes of uncommon conditions and events in orthopaedic surgery. Bone Jt Open 2020; 1:41-46. [PMID: 33215106 PMCID: PMC7659705 DOI: 10.1302/2633-1462.13.bjo-2020-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery. Methods The BOSS Study is a series of nationwide observational cohort studies of pre-specified orthopaedic disease. All relevant hospitals treating the disease are invited to contribute anonymised case details. Data will be collected digitally through REDCap, with an additional bespoke software solution used to regularly confirm case ascertainment, prompt follow-up reminders and identify potential missing cases from external sources of information (i.e. national administrative data). With their consent, patients will be invited to enrich the data collected by supplementing anonymised case data with patient reported outcomes. The study will primarily seek to calculate the incidence of the rare diseases under investigation, with 95% confidence intervals. Descriptive statistics will be used to describe the case mix, treatment variations and outcomes. Inferential statistical analysis may be used to analyze associations between presentation factors and outcomes. Types of analyses will be contingent on the disease under investigation. Discussion This study builds upon other national rare disease supporting structures, particularly those in obstetrics and paediatric surgery. It is particularly focused on addressing the evidence base for quality and safety of surgery, and the design is influenced by the specifications of the IDEAL collaboration for the development of surgical research.
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Affiliation(s)
- Daniel C Perry
- University of Liverpool; Institute of Translational Medicine, Alder Hey Hospital, Liverpool, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Barbara Arch
- University of Liverpool; Institute of Translational Medicine, Alder Hey Hospital, Eaton Road, Liverpool
| | - Duncan Appelbe
- NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, Oxfordshire, UK OX3 9DU
| | - Priya Francis
- University of Liverpool; Institute of Translational Medicine, Alder Hey Hospital, Eaton Road, Liverpool
| | - Catherine Spowart
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK OX3 7LF
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Lobban F, Appelbe D, Appleton V, Aref-Adib G, Barraclough J, Billsborough J, Fisher NR, Foster S, Gill B, Glentworth D, Harrop C, Johnson S, Jones SH, Kovacs TZ, Lewis E, Mezes B, Morton C, Murray E, O’Hanlon P, Pinfold V, Rycroft-Malone J, Siddle R, Smith J, Sutton CJ, Viglienghi P, Walker A, Wintermeyer C. An online supported self-management toolkit for relatives of people with psychosis or bipolar experiences: the IMPART multiple case study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Digital health interventions have the potential to improve the delivery of psychoeducation to people with mental health problems and their relatives. Despite substantial investment in the development of digital health interventions, successful implementation into routine clinical practice is rare.
Objectives
Use the implementation of the Relatives’ Education And Coping Toolkit (REACT) for psychosis/bipolar disorder to identify critical factors affecting uptake and use, and develop an implementation plan to support the delivery of REACT.
Design
This was an implementation study using a mixed-methods, theory-driven, multiple case study approach. A study-specific implementation theory for REACT based on normalisation process theory was developed and tested, and iterations of an implementation plan to address the key factors affecting implementation were developed.
Setting
Early-intervention teams in six NHS mental health trusts in England (three in the north and three in the south).
Participants
In total, 281 staff accounts and 159 relatives’ accounts were created, 129 staff and 23 relatives took part in qualitative interviews about their experiences, and 132 relatives provided demographic data, 56 provided baseline data, 21 provided data at 12 weeks’ follow-up and 20 provided data at 24 weeks’ follow-up.
Interventions
REACT is an online supported self-management toolkit, offering 12 evidence-based psychoeducation modules and support via a forum, and a confidential direct messaging service for relatives of people with psychosis or bipolar disorder. The implementation intervention was developed with staff and iteratively adapted to address identified barriers. Adaptations included modifications to the toolkit and how it was delivered by teams.
Main outcome measures
The main outcome was factors affecting implementation of REACT, assessed primarily through in-depth interviews with staff and relatives. We also assessed quantitative measures of delivery (staff accounts and relatives’ invitations), use of REACT (relatives’ logins and time spent on the website) and the impact of REACT [relatives’ distress (General Health Questionnaire-28), and carer well-being and support (Carer Well-being and Support Scale questionnaire)].
Results
Staff and relatives were generally positive about the content of REACT, seeing it as a valuable resource that could help services improve support and meet clinical targets, but only within a comprehensive service that included face-to-face support, and with some additional content. Barriers to implementation included high staff caseloads and difficulties with prioritising supporting relatives; technical difficulties of using REACT; poor interoperability with trust information technology systems and care pathways; lack of access to mobile technology and information technology training; restricted forum populations leading to low levels of use; staff fears of managing risk, online trolling, or replacement by technology; and uncertainty around REACT’s long-term availability. There was no evidence that REACT would reduce staff time supporting relatives (which was already very low), and might increase it by facilitating communication. In all, 281 staff accounts were created, but only 57 staff sent relatives invitations. In total, 355 relatives’ invitations were sent to 310 unique relatives, leading to the creation of 159 relatives’ accounts. The mean number of logins for relatives was 3.78 (standard deviation 4.43), but with wide variation from 0 to 31 (median 2, interquartile range 1–8). The mean total time spent on the website was 40.6 minutes (standard deviation 54.54 minutes), with a range of 0–298 minutes (median 20.1 minutes, interquartile range 4.9–57.5 minutes). There was a pattern of declining mean scores for distress, social dysfunction, depression, anxiety and insomnia, and increases in relatives’ well-being and eHealth literacy, but no changes were statistically significant.
Conclusions
Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, with staff and service user input, as part of a long-term strategy to develop integrated technology-enabled services. Implementation strategies must instil a sense of ownership for staff and ensure that they have adequate training, risk protocols and resources to deliver the technology. Cost-effectiveness and impact on workload and inequalities in accessing health care need further testing, along with the generalisability of our findings to other digital health interventions.
Limitations
REACT was offered by the same team running the IMPlementation of A Relatives’ Toolkit (IMPART) study, and was perceived by staff and relatives as a time-limited research study rather than ongoing clinical service, which affected engagement. Access to observational data was limited.
Trial registration
Current Controlled Trials ISRCTN16267685.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 37. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona Lobban
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Duncan Appelbe
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | | | | | | | | | - Naomi R Fisher
- Division of Health Research, Lancaster University, Lancaster, UK
| | | | - Bethany Gill
- Division of Health Research, Lancaster University, Lancaster, UK
| | | | | | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Steven H Jones
- Division of Health Research, Lancaster University, Lancaster, UK
| | | | - Elizabeth Lewis
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Barbara Mezes
- Division of Health Research, Lancaster University, Lancaster, UK
| | | | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Puffin O’Hanlon
- Division of Psychiatry, University College London, London, UK
| | | | | | | | - Jo Smith
- School of Allied Health and Community, University of Worcester, Worcester, UK
| | - Chris J Sutton
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | | | - Andrew Walker
- Division of Health Research, Lancaster University, Lancaster, UK
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Robinson H, Appelbe D, Dodd S, Flowers S, Johnson S, Jones SH, Mateus C, Mezes B, Murray E, Rainford N, Rosala-Hallas A, Walker A, Williamson P, Lobban F. Methodological Challenges in Web-Based Trials: Update and Insights From the Relatives Education and Coping Toolkit Trial. JMIR Ment Health 2020; 7:e15878. [PMID: 32497018 PMCID: PMC7395253 DOI: 10.2196/15878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 03/02/2020] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
RR2-10.1136/bmjopen-2017-016965.
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Affiliation(s)
- Heather Robinson
- Division of Health Research, Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, United Kingdom
| | - Duncan Appelbe
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Susanna Dodd
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Susan Flowers
- Division of Health Research, Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, United Kingdom
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, United Kingdom
| | - Steven H Jones
- Division of Health Research, Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, United Kingdom
| | - Céu Mateus
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Barbara Mezes
- Division of Health Research, Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, United Kingdom
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Naomi Rainford
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Anna Rosala-Hallas
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Andrew Walker
- Division of Health Research, Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, United Kingdom
| | - Paula Williamson
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Fiona Lobban
- Division of Health Research, Spectrum Centre for Mental Health Research, Lancaster University, Lancaster, United Kingdom
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Achten J, Knight R, Dutton SJ, Costa ML, Mason J, Dritsaki M, Appelbe D, Messahel S, Roland D, Widnall J, Perry DC. A multicentre prospective randomized equivalence trial of a soft bandage and immediate discharge versus current treatment with rigid immobilization for torus fractures of the distal radius in children: protocol for the Forearm Fracture Recovery in Children Evaluation (FORCE) trial. Bone Jt Open 2020; 1:214-221. [PMID: 33225292 PMCID: PMC7677722 DOI: 10.1302/2633-1462.16.bjo-2020-0014.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS Torus fractures are the most common childhood fracture, accounting for 500,000 UK emergency attendances per year. UK treatment varies widely due to lack of scientific evidence. This is the protocol for a randomized controlled equivalence trial of 'the offer of a soft bandage and immediate discharge' versus 'rigid immobilization and follow-up as per the protocol of the treating centre' in the treatment of torus fractures . METHODS Children aged four to 15-years-old inclusive who have sustained a torus/buckle fracture of the distal radius with/without an injury to the ulna are eligible to take part. Baseline pain as measured by the Wong Baker FACES pain scale, function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb, and quality of life (QoL) assessed with the EuroQol EQ-5D-Y will be collected. Each patient will be randomly allocated (1:1, stratified by centre and age group (four to seven years and ≥ eight years) to either a regimen of the offer of a soft bandage and immediate discharge or rigid immobilization and follow-up as per the protocol of the treating centre. RESULTS At day one, three, and seven, data on pain, function, QoL, immobilization, and analgesia will be collected. Three and six weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the Wong-Baker FACES pain scale at three days post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardian.Cite this article: Bone Joint Open 2020;1-6:214-221.
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Affiliation(s)
- Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J. Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Matthew L. Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - James Mason
- Centre for Health Economics at Warwick, Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Shrouk Messahel
- Institute in the Park, Alder Hey Children’s Hospital, Liverpool, UK
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
| | - James Widnall
- Institute in the Park, Alder Hey Children’s Hospital, Liverpool, UK
| | - Daniel C. Perry
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Institute in the Park, Alder Hey Children’s Hospital, Liverpool, UK
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Koneska E, Appelbe D, Williamson PR, Dodd S. Usage Metrics of Web-Based Interventions Evaluated in Randomized Controlled Trials: Systematic Review. J Med Internet Res 2020; 22:e15474. [PMID: 32297870 PMCID: PMC7193439 DOI: 10.2196/15474] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/24/2019] [Accepted: 01/26/2020] [Indexed: 11/21/2022] Open
Abstract
Background The evaluation of web-based interventions (defined as an intervention that can be downloaded or accessed on the internet through a web browser) in randomized controlled trials (RCTs) has increased over the past two decades. Little is known about how participants’ use of the intervention is measured, reported, and analyzed in these studies. Objective This study aimed to review the evaluation of web-based interventions in RCTs, assessing study characteristics and the methods used to record, and adjust for, intervention usage. Methods A systematic review of the literature was undertaken to identify all published reports of RCTs that involved a web-based intervention. A random sample of 100 published trials was selected for detailed data extraction. Information on trial characteristics was extracted, including whether web usage data were recorded, and if so, the methods used to gather these data and whether these data were used to inform efficacy analyses. Results A PubMed search identified 812 trials of web-based interventions published up to the end of 2017 and demonstrated a growing trend over time. Of the 100 studies reviewed, 90 studies collected web usage data, but more than half (49/90, 54%) of these studies did not state the method used for recording web usage. Only four studies attempted to check on the reliability of their web usage data collection methods. A total of 39% (35/90) studies reported patterns or levels of web intervention use, of which 21% (19/90) studies adjusted for intervention use in their outcome analysis, but only two of these used appropriate statistical methods. Conclusions Trialists frequently report a measure of web-based intervention usage but do not always report the collection method or provide enough detail on their analysis of web usage. Appropriate statistical methods to account for intervention use are rarely used and are not well reported even in the very few trials in which they are used. The number of trialists who attempt to check on the reliability of their web usage collection methods is extremely low.
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Affiliation(s)
- Elena Koneska
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Duncan Appelbe
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom.,Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Susanna Dodd
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
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25
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Lobban F, Akers N, Appelbe D, Chapman L, Collinge L, Dodd S, Flowers S, Hollingsworth B, Johnson S, Jones SH, Mateus C, Mezes B, Murray E, Panagaki K, Rainford N, Robinson H, Rosala-Hallas A, Sellwood W, Walker A, Williamson P. Clinical effectiveness of a web-based peer-supported self-management intervention for relatives of people with psychosis or bipolar (REACT): online, observer-blind, randomised controlled superiority trial. BMC Psychiatry 2020; 20:160. [PMID: 32290827 PMCID: PMC7158157 DOI: 10.1186/s12888-020-02545-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/11/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Relatives Education And Coping Toolkit (REACT) is an online supported self-management toolkit for relatives of people with psychosis or bipolar designed to improve access to NICE recommended information and emotional support. AIMS Our aim was to determine clinical and cost-effectiveness of REACT including a Resource Directory (RD), versus RD-only. METHODS A primarily online, observer-blind randomised controlled trial comparing REACT (including RD) with RD only (registration ISRCTN72019945). Participants were UK relatives aged > = 16, with high distress (assessed using the GHQ-28), and actively help-seeking, individually randomised, and assessed online. Primary outcome was relatives' distress (GHQ-28) at 24 weeks. Secondary outcomes were wellbeing, support, costs and user feedback. RESULTS We recruited 800 relatives (REACT = 399; RD only = 401) with high distress at baseline (GHQ-28 REACT mean 40.3, SD 14.6; RD only mean 40.0, SD 14.0). Median time spent online on REACT was 50.8 min (IQR 12.4-172.1) versus 0.5 min (IQR 0-1.6) on RD only. Retention to primary follow-up (24 weeks) was 75% (REACT n = 292 (73.2%); RD-only n = 307 (76.6%)). Distress decreased in both groups by 24 weeks, with no significant difference between the two groups (- 1.39, 95% CI -3.60, 0.83, p = 0.22). Estimated cost of delivering REACT was £62.27 per person and users reported finding it safe, acceptable and convenient. There were no adverse events or reported side effects. CONCLUSIONS REACT is an inexpensive, acceptable, and safe way to deliver NICE-recommended support for relatives. However, for highly distressed relatives it is no more effective in reducing distress (GHQ-28) than a comprehensive online resource directory. TRIAL REGISTRATION ISRCTN72019945 prospectively registered 19/11/2015.
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Affiliation(s)
- Fiona Lobban
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Nadia Akers
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Duncan Appelbe
- grid.10025.360000 0004 1936 8470Clinical Trials Research Centre, Institute of Child Health, Alder Hey, University of Liverpool, Liverpool, UK
| | - Lesley Chapman
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lizzi Collinge
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Susanna Dodd
- grid.10025.360000 0004 1936 8470Clinical Trials Research Centre, Institute of Child Health, Alder Hey, University of Liverpool, Liverpool, UK
| | - Sue Flowers
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Bruce Hollingsworth
- grid.9835.70000 0000 8190 6402Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Sonia Johnson
- grid.83440.3b0000000121901201University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Steven H. Jones
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Ceu Mateus
- grid.9835.70000 0000 8190 6402Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Barbara Mezes
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Elizabeth Murray
- grid.83440.3b0000000121901201e-Health and Primary Care, Primary Care & Population Health Institute of Epidemiology & Health, Faculty of Pop Health Sciences, University College London, London, UK
| | - Katerina Panagaki
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Naomi Rainford
- grid.10025.360000 0004 1936 8470Clinical Trials Research Centre, Institute of Child Health, Alder Hey, University of Liverpool, Liverpool, UK
| | - Heather Robinson
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Anna Rosala-Hallas
- grid.10025.360000 0004 1936 8470Clinical Trials Research Centre, Institute of Child Health, Alder Hey, University of Liverpool, Liverpool, UK
| | - William Sellwood
- grid.9835.70000 0000 8190 6402Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Andrew Walker
- grid.9835.70000 0000 8190 6402Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Paula Williamson
- grid.10025.360000 0004 1936 8470Clinical Trials Research Centre, Institute of Child Health, Alder Hey, University of Liverpool, Liverpool, UK
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Broadbent DM, Sampson CJ, Wang A, Howard L, Williams AE, Howlin SU, Appelbe D, Moitt T, Cheyne CP, Rahni MM, Kelly J, Collins J, García-Fiñana M, Stratton IM, James M, Harding SP. Individualised screening for diabetic retinopathy: the ISDR study-rationale, design and methodology for a randomised controlled trial comparing annual and individualised risk-based variable-interval screening. BMJ Open 2019; 9:e025788. [PMID: 31213445 PMCID: PMC6588999 DOI: 10.1136/bmjopen-2018-025788] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Currently, all people with diabetes (PWD) aged 12 years and over in the UK are invited for screening for diabetic retinopathy (DR) annually. Resources are not increasing despite a 5% increase in the numbers of PWD nationwide each year. We describe the rationale, design and methodology for a randomised controlled trial (RCT) evaluating the safety, acceptability and cost-effectiveness of personalised variable-interval risk-based screening for DR. This is the first randomised trial of personalised screening for DR and the largest ophthalmic RCT in the UK. METHODS AND ANALYSIS PWD attending seven screening clinics in the Liverpool Diabetic Eye Screening Programme were recruited into a single site RCT with a 1:1 allocation to individualised risk-based variable-interval or annual screening intervals. A risk calculation engine developed for the trial estimates the probability that an individual will develop referable disease (screen positive DR) within the next 6, 12 or 24 months using demographic, retinopathy and systemic risk factor data from primary care and screening programme records. Dynamic, secure, real-time data connections have been developed. The primary outcome is attendance for follow-up screening. We will test for equivalence in attendance rates between the two arms. Secondary outcomes are rates and severity of DR, visual outcomes, cost-effectiveness and health-related quality of life. The required sample size was 4460 PWD. Recruitment is complete, and the trial is in follow-up. ETHICS AND DISSEMINATION Ethical approval was obtained from National Research Ethics Service Committee North West - Preston, reference 14/NW/0034. Results will be presented at international meetings and published in peer-reviewed journals. This pragmatic RCT will inform screening policy in the UK and elsewhere. TRIAL REGISTRATION NUMBER ISRCTN87561257; Pre-results.
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Affiliation(s)
- Deborah M Broadbent
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- St Pauls Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Christopher J Sampson
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amu Wang
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Lola Howard
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Abigail E Williams
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Susan U Howlin
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Duncan Appelbe
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Tracy Moitt
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Christopher P Cheyne
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Mehrdad Mobayen Rahni
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - John Kelly
- Patient and Public Involvement Group, Liverpool, UK
| | - John Collins
- Patient and Public Involvement Group, Liverpool, UK
| | - Marta García-Fiñana
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Cheltenham, UK
| | - Marilyn James
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- St Pauls Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
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27
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Abstract
Numerous studies have confirmed that prelinguistic utterances are precursors to speech, and there is ample evidence that, for example, frequency of canonical syllables and syllable inventory size correlate with speech and language measures at older ages. Traditionally, prelinguistic utterances have been assessed by phonetic transcription which is difficult and time-consuming in infants. Recently, a more time-efficient methodology to assess prelinguistic utterances in real time, called naturalistic listening, was developed (Ramsdell et al., 2012). In a large international NIDCR-funded randomized controlled trial, Timing of Primary Surgery for with Cleft Palate (TOPS), including many coders, a software program (TimeStamper) was developed to assist in coding of prelinguistic vocalizations in real time, to ensure consistency of the coding procedures. Coders upload a video (or audio) file and watch and listen to the recording in real time without any possibility of pausing or taking notes. In real time, the coder registers each speech-like syllable as canonical or non-canonical. TimeStamper automatically calculates the percentage of canonical syllables of all syllables registered (canonical babbling ratio). At the end of a recording, TimeStamper assists in assessing presence/absence of canonical babbling and syllable inventory size. The software is presented and instructions for free access are provided.
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Affiliation(s)
- Elisabeth Willadsen
- Department of Nordic Studies and Linguistics, University of Copenhagen, Denmark
| | - Christina Persson
- Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Duncan Appelbe
- Clinical Trials Research Centre, University of Liverpool, United Kingdom
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28
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Lobban F, Appleton V, Appelbe D, Barraclough J, Bowland J, Fisher NR, Foster S, Johnson S, Lewis E, Mateus C, Mezes B, Murray E, O'Hanlon P, Pinfold V, Rycroft-Malone J, Siddle R, Smith J, Sutton CJ, Walker A, Jones SH. IMPlementation of A Relatives' Toolkit (IMPART study): an iterative case study to identify key factors impacting on the implementation of a web-based supported self-management intervention for relatives of people with psychosis or bipolar experiences in a National Health Service: a study protocol. Implement Sci 2017; 12:152. [PMID: 29282135 PMCID: PMC5745602 DOI: 10.1186/s13012-017-0687-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/28/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Web-based interventions to support people to manage long-term health conditions are available and effective but rarely used in clinical services. The aim of this study is to identify critical factors impacting on the implementation of an online supported self-management intervention for relatives of people with recent onset psychosis or bipolar disorder into routine clinical care and to use this information to inform an implementation plan to facilitate widespread use and inform wider implementation of digital health interventions. METHODS A multiple case study design within six early intervention in psychosis (EIP) services in England, will be used to test and refine theory-driven hypotheses about factors impacting on implementation of the Relatives' Education And Coping Toolkit (REACT). Qualitative data including behavioural observation, document analysis, and in-depth interviews collected in the first two EIP services (wave 1) and analysed using framework analysis, combined with quantitative data describing levels of use by staff and relatives and impact on relatives' distress and wellbeing, will be used to identify factors impacting on implementation. Consultation via stakeholder workshops with staff and relatives and co-facilitated by relatives in the research team will inform development of an implementation plan to address these factors, which will be evaluated and refined in the four subsequent EIP services in waves 2 and 3. Transferability of the implementation plan to non-participating services will be explored. DISCUSSION Observation of implementation in a real world clinical setting, across carefully sampled services, in real time provides a unique opportunity to understand factors impacting on implementation likely to be generalizable to other web-based interventions, as well as informing further development of implementation theories. However, there are inherent challenges in investigating implementation without influencing the process under observation. We outline our strategies to ensure our design is transparent, flexible, and responsive to the timescales and activities happening within each service whilst also meeting the aims of the project. TRIAL REGISTRATION ISCTRN 16267685 (09/03/2016).
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Affiliation(s)
- Fiona Lobban
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK.
| | - Victoria Appleton
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Duncan Appelbe
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Block F, Waterhouse Bld 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Johanna Barraclough
- Doctorate in Clinical Psychology Programme, Furness College, Lancaster University, Lancaster, LA1 4YG, UK
| | - Julie Bowland
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Naomi R Fisher
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Sheena Foster
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, 6th Floor, Maple House, London, W1T 7BN, UK
| | - Elizabeth Lewis
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Céu Mateus
- Division of Health Research, Lancaster University Furness College, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Barbara Mezes
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, Upper floor 3, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Puffin O'Hanlon
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Vanessa Pinfold
- The McPin Foundation, 32-36 Loman Street, London, SE1 0EH, UK
| | - Jo Rycroft-Malone
- Bangor Institute for Health & Medical Research, School of Healthcare Sciences, Bangor University, College Road, Bangor, LL572DG, UK
| | - Ron Siddle
- Cumbria Partnership NHS Foundation Trust, Penrith, UK
| | - Jo Smith
- Institute of Health and Society, University of Worcester, Henwick Grove, Worcester, WR2 6AJ, UK
| | - Chris J Sutton
- Lancashire Clinical Trials Unit, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Andrew Walker
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
| | - Steven H Jones
- Spectrum Centre for Mental Health Research, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Bailrigg, Lancaster, LA1 4YW, UK
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McCann LJ, Pilkington CA, Huber AM, Ravelli A, Appelbe D, Kirkham JJ, Williamson PR, Aggarwal A, Christopher-Stine L, Constantin T, Feldman BM, Lundberg I, Maillard S, Mathiesen P, Murphy R, Pachman LM, Reed AM, Rider LG, van Royen-Kerkof A, Russo R, Spinty S, Wedderburn LR, Beresford MW. Development of a consensus core dataset in juvenile dermatomyositis for clinical use to inform research. Ann Rheum Dis 2017; 77:241-250. [PMID: 29084729 PMCID: PMC5816738 DOI: 10.1136/annrheumdis-2017-212141] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/23/2017] [Accepted: 10/01/2017] [Indexed: 01/07/2023]
Abstract
Objectives This study aimed to develop consensus on an internationally agreed dataset for juvenile dermatomyositis (JDM), designed for clinical use, to enhance collaborative research and allow integration of data between centres. Methods A prototype dataset was developed through a formal process that included analysing items within existing databases of patients with idiopathic inflammatory myopathies. This template was used to aid a structured multistage consensus process. Exploiting Delphi methodology, two web-based questionnaires were distributed to healthcare professionals caring for patients with JDM identified through email distribution lists of international paediatric rheumatology and myositis research groups. A separate questionnaire was sent to parents of children with JDM and patients with JDM, identified through established research networks and patient support groups. The results of these parallel processes informed a face-to-face nominal group consensus meeting of international myositis experts, tasked with defining the content of the dataset. This developed dataset was tested in routine clinical practice before review and finalisation. Results A dataset containing 123 items was formulated with an accompanying glossary. Demographic and diagnostic data are contained within form A collected at baseline visit only, disease activity measures are included within form B collected at every visit and disease damage items within form C collected at baseline and annual visits thereafter. Conclusions Through a robust international process, a consensus dataset for JDM has been formulated that can capture disease activity and damage over time. This dataset can be incorporated into national and international collaborative efforts, including existing clinical research databases.
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Affiliation(s)
- Liza J McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Clarissa A Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, University College London Hospital, London, UK
| | - Adam M Huber
- Division of Pediatric Rheumatology, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Angelo Ravelli
- Division of Rheumatology, Università degli Studi di Genova and Istituto Giannina Gaslini Pediatria II-Reumatologia, Genoa, Italy
| | - Duncan Appelbe
- Department of Biostatistics, MRC North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Jamie J Kirkham
- Department of Biostatistics, MRC North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Paula R Williamson
- Department of Biostatistics, MRC North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Amita Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | - Tamas Constantin
- 2nd Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Brian M Feldman
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Ingrid Lundberg
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sue Maillard
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Pernille Mathiesen
- Department of Paediatrics and Adolescent Medicine, Naestved Hospital, Region Zeeland, Naestved, Denmark
| | - Ruth Murphy
- Department of Dermatology, Royal Hallamshire Hospital, Sheffield, UK
| | - Lauren M Pachman
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Centre for Clinical Immunology, The Stanley Manne Children's Research Centre, Chicago, Illinois, USA
| | - Ann M Reed
- Department of Paediatrics, Duke University, Durham, North Carolina, USA
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, Bethesda, Maryland, USA
| | - Annet van Royen-Kerkof
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital University Medical Centre, Utrecht, The Netherlands
| | - Ricardo Russo
- Department of Paediatric Immunology and Rheumatology, Paediatric Hospital Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Stefan Spinty
- Department of Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lucy R Wedderburn
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, University College London Hospital, London, UK.,Infection, Immunology, and Rheumatology Section, UCL GOS Institute of Child Health, University College London, London, UK.,NIHR-Biomedical Research Centre at GOSH, London, UK
| | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Irwin AD, Grant A, Williams R, Kolamunnage-Dona R, Drew RJ, Paulus S, Jeffers G, Williams K, Breen R, Preston J, Appelbe D, Chesters C, Newland P, Marzouk O, McNamara PS, Diggle PJ, Carrol ED. Predicting Risk of Serious Bacterial Infections in Febrile Children in the Emergency Department. Pediatrics 2017; 140:peds.2016-2853. [PMID: 28679639 DOI: 10.1542/peds.2016-2853] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Improving the diagnosis of serious bacterial infections (SBIs) in the children's emergency department is a clinical priority. Early recognition reduces morbidity and mortality, and supporting clinicians in ruling out SBIs may limit unnecessary admissions and antibiotic use. METHODS A prospective, diagnostic accuracy study of clinical and biomarker variables in the diagnosis of SBIs (pneumonia or other SBI) in febrile children <16 years old. A diagnostic model was derived by using multinomial logistic regression and internally validated. External validation of a published model was undertaken, followed by model updating and extension by the inclusion of procalcitonin and resistin. RESULTS There were 1101 children studied, of whom 264 had an SBI. A diagnostic model discriminated well between pneumonia and no SBI (concordance statistic 0.84, 95% confidence interval 0.78-0.90) and between other SBIs and no SBI (0.77, 95% confidence interval 0.71-0.83) on internal validation. A published model discriminated well on external validation. Model updating yielded good calibration with good performance at both high-risk (positive likelihood ratios: 6.46 and 5.13 for pneumonia and other SBI, respectively) and low-risk (negative likelihood ratios: 0.16 and 0.13, respectively) thresholds. Extending the model with procalcitonin and resistin yielded improvements in discrimination. CONCLUSIONS Diagnostic models discriminated well between pneumonia, other SBIs, and no SBI in febrile children in the emergency department. Improvements in the classification of nonevents have the potential to reduce unnecessary hospital admissions and improve antibiotic prescribing. The benefits of this improved risk prediction should be further evaluated in robust impact studies.
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Affiliation(s)
| | | | | | | | - Richard J Drew
- Department of Microbiology, Rotunda Hospital, Dublin, Ireland.,Department of Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
| | | | | | | | - Rachel Breen
- Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | | | - Duncan Appelbe
- Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Christine Chesters
- Biochemistry, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Paul Newland
- Biochemistry, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Peter J Diggle
- Institute of Infection and Global Health.,Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, United Kingdom
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31
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Lobban F, Robinson H, Appelbe D, Barraclough J, Bedson E, Collinge L, Dodd S, Flowers S, Honary M, Johnson S, Mateus C, Mezes B, Minns V, Murray E, Walker A, Williamson P, Wintermeyer C, Jones S. Protocol for an online randomised controlled trial to evaluate the clinical and cost-effectiveness of a peer-supported self-management intervention for relatives of people with psychosis or bipolar disorder: Relatives Education And Coping Toolkit (REACT). BMJ Open 2017; 7:e016965. [PMID: 28720617 PMCID: PMC5541455 DOI: 10.1136/bmjopen-2017-016965] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Despite clinical guidelines recommendations, many relatives of people with psychosis or bipolar disorder do not currently receive the support they need. Online information and support may offer a solution. METHODS AND ANALYSIS This single-blind, parallel, online randomised controlled trial will determine clinical and cost-effectiveness of the Relatives Education And Coping Toolkit (REACT) (including an online resource directory (RD)), compared with RD only, for relatives of people with psychosis or bipolar disorder. Both groups continue to receive treatment as usual. Independent, web-based variable, block, individual randomisation will be used across 666 relatives. Primary outcome is distress at 24 weeks (measured by General Health Questionnaire; GHQ-28) compared between groups using analysis of covariance, adjusting for baseline score. Secondary clinical outcomes are carer well-being and support. Cost-effectiveness analysis will determine cost of a significant unit change (three-point reduction) in the GHQ-28. Costs include offering and supporting the intervention in the REACT arm, relevant healthcare care costs including health professional contacts, medications prescribed and time off (or ability to) work for the relative. Cost utility analysis will be calculated as the marginal cost of changes in quality-adjusted life years, based on EuroQol. We will explore relatives' beliefs, perceived coping and amount of REACT toolkit use as possible outcome mediators. We have embedded two methodological substudies in the protocol to determine the relative effectiveness of a low-value (£10) versus higher value (£20) incentive, and an unconditional versus conditional incentive, on improving follow-up rates. ETHICS AND DISSEMINATION The trial has ethical approval from Lancaster National Research Ethics Service (NRES)Committee (15/NW/0732) and is overseen by an independent Data Monitoring and Ethics Committee and Trial Steering Committee. Protocol version 1.5 was approved on 9 January 2017. All updates to protocols are uploaded to the National Institute for Health Research (NIHR) Journals Library. A full statistical analysis plan is available at https://figshare.com/account/home#/projects/19975. Publications will be in peer-reviewed journals (open access wherever possible). Requests for access to the data at the end of the study will be reviewed and granted where appropriate by the Trial Management Group. TRIAL REGISTRATION NUMBER ISRCTN72019945, pre-results.
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Affiliation(s)
- Fiona Lobban
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Heather Robinson
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Duncan Appelbe
- Medical Research Council North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Johanna Barraclough
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Emma Bedson
- Medical Research Council North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Lizzie Collinge
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Susanna Dodd
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Sue Flowers
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Mahsa Honary
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Ceu Mateus
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Barbara Mezes
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Valerie Minns
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Elizabeth Murray
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Andrew Walker
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Paula Williamson
- Medical Research Council North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Catherine Wintermeyer
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Steven Jones
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
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32
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Tudur Smith C, Nevitt S, Appelbe D, Appleton R, Dixon P, Harrison J, Marson A, Williamson P, Tremain E. Resource implications of preparing individual participant data from a clinical trial to share with external researchers. Trials 2017; 18:319. [PMID: 28712359 PMCID: PMC5512949 DOI: 10.1186/s13063-017-2067-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/15/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Demands are increasingly being made for clinical trialists to actively share individual participant data (IPD) collected from clinical trials using responsible methods that protect the confidentiality and privacy of clinical trial participants. Clinical trialists, particularly those receiving public funding, are often concerned about the additional time and money that data-sharing activities will require, but few published empirical data are available to help inform these decisions. We sought to evaluate the activity and resources required to prepare anonymised IPD from a clinical trial in anticipation of a future data-sharing request. METHODS Data from two UK publicly funded clinical trials were used for this exercise: 2437 participants with epilepsy recruited from 90 hospital outpatient clinics in the SANAD trial and 146 children with neuro-developmental problems recruited from 18 hospitals in the MENDS trial. We calculated the time and resources required to prepare each anonymised dataset and assemble a data pack ready for sharing. RESULTS The older SANAD trial (published 2007) required 50 hours of staff time with a total estimated associated cost of £3185 whilst the more recently completed MENDS trial (published 2012) required 39.5 hours of staff time with total estimated associated cost of £2540. CONCLUSIONS Clinical trial researchers, funders and sponsors should consider appropriate resourcing and allow reasonable time for preparing IPD ready for subsequent sharing. This process would be most efficient if prospectively built into the standard operational design and conduct of a clinical trial. Further empirical examples exploring the resource requirements in other settings is recommended. TRIAL REGISTRATION SANAD: International Standard Randomised Controlled Trials Registry: ISRCTN38354748 . Registered on 25 April 2003. MENDS EU Clinical Trials Register Eudract 2006-004025-28 . Registered on 16 May 2007. International Standard Randomised Controlled Trials Registry: ISRCTN05534585 /MREC 07/MRE08/43. Registered on 26 January 2007.
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Affiliation(s)
- Catrin Tudur Smith
- Department of Biostatistics, University of Liverpool, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Sarah Nevitt
- Department of Biostatistics, University of Liverpool, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Duncan Appelbe
- Department of Biostatistics, University of Liverpool, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | | | - Pete Dixon
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Janet Harrison
- Department of Biostatistics, University of Liverpool, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Anthony Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Paula Williamson
- Department of Biostatistics, University of Liverpool, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Elizabeth Tremain
- National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Southampton, UK
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Appelbe D, Broadbent D, Mobayen-Rahni M, Eleuteri A, Bennett A, Moitt T, Wang A, García-Fiñana M, Fisher A, Harding S. Introducing personalised risk based intervals in screening for diabetic retinopathy: development, implementation and assessment of safety, cost-effectiveness and patient experience (ISDR): a case study in the use of automated systems in trials. Trials 2015. [PMCID: PMC4658818 DOI: 10.1186/1745-6215-16-s2-o59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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34
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Appelbe D, Adeogun O, Webb N, Majeed R, Lewis M, Williamson P. Development and evaluation of an electronic diary for recording patient reported outcomes in the overt study. Trials 2015. [PMCID: PMC4658787 DOI: 10.1186/1745-6215-16-s2-o64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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McCann LJ, Kirkham JJ, Wedderburn LR, Pilkington C, Huber AM, Ravelli A, Appelbe D, Williamson PR, Beresford MW. Development of an internationally agreed minimal dataset for juvenile dermatomyositis (JDM) for clinical and research use. Trials 2015; 16:268. [PMID: 26063230 PMCID: PMC4472260 DOI: 10.1186/s13063-015-0784-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/29/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a rare autoimmune inflammatory disorder associated with significant morbidity and mortality. International collaboration is necessary to better understand the pathogenesis of the disease, response to treatment and long-term outcome. To aid international collaboration, it is essential to have a core set of data that all researchers and clinicians collect in a standardised way for clinical purposes and for research. This should include demographic details, diagnostic data and measures of disease activity, investigations and treatment. Variables in existing clinical registries have been compared to produce a provisional data set for JDM. We now aim to develop this into a consensus-approved minimum core dataset, tested in a wider setting, with the objective of achieving international agreement. METHODS/DESIGN A two-stage bespoke Delphi-process will engage the opinion of a large number of key stakeholders through Email distribution via established international paediatric rheumatology and myositis organisations. This, together with a formalised patient/parent participation process will help inform a consensus meeting of international experts that will utilise a nominal group technique (NGT). The resulting proposed minimal dataset will be tested for feasibility within existing database infrastructures. The developed minimal dataset will be sent to all internationally representative collaborators for final comment. The participants of the expert consensus group will be asked to draw together these comments, ratify and 'sign off' the final minimal dataset. DISCUSSION An internationally agreed minimal dataset has the potential to significantly enhance collaboration, allow effective communication between groups, provide a minimal standard of care and enable analysis of the largest possible number of JDM patients to provide a greater understanding of this disease. The final approved minimum core dataset could be rapidly incorporated into national and international collaborative efforts, including existing prospective databases, and be available for use in randomised controlled trials and for treatment/protocol comparisons in cohort studies.
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Affiliation(s)
- Liza J McCann
- Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK.
| | - Jamie J Kirkham
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Lucy R Wedderburn
- Infection, Immunology, and Rheumatology Section UCL Institute of Child Health, University College London, London, UK. .,Great Ormond Street Hospital NHS Foundation Trust, London, UK. .,Centre for Adolescent Rheumatology at University College London, University College London Hospital, London, UK.
| | - Clarissa Pilkington
- Great Ormond Street Hospital NHS Foundation Trust, London, UK. .,Centre for Adolescent Rheumatology at University College London, University College London Hospital, London, UK.
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, 5850 University Avenue, Halifax, NS, B3K 6R8, Canada.
| | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy.
| | - Duncan Appelbe
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Paula R Williamson
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Michael W Beresford
- Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK. .,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
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Garrett PE, Ormand WE, Appelbe D, Bauer RW, Becker JA, Bernstein LA, Cameron JA, Carpenter MP, Janssens RV, Lister CJ, Seweryniak D, Tavukcu E, Warner DD. Observation of (46)Cr and testing the isobaric multiplet mass equation at high spin. Phys Rev Lett 2001; 87:132502. [PMID: 11580579 DOI: 10.1103/physrevlett.87.132502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2001] [Indexed: 05/23/2023]
Abstract
The ground state band in (46)Cr and the isospin T = 1 band in (46)V have been delineated up to Ipi = 10(+) (tentatively 12(+)). These observations complete the highest spin T = 1 isospin triplet known. Following the isobaric multiplet mass equation, a combination of level energies in (46)Cr, (46)Ti, and (46)V are taken to highlight the angular momentum dependence of the isovector and isotensor parts of the interaction. The results are compared with full- fp-space shell model calculations. The influence of the one-body and two-body contributions to the isovector energy difference are investigated.
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Affiliation(s)
- P E Garrett
- Lawrence Livermore National Laboratory, Livermore, California 94551, USA
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37
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Savajols H, Korichi A, Ward D, Appelbe D, Ball GC, Beausang C, Beck FA, Byrski T, Curien D, Dagnall P, Disdier D, Duchêne G, Erturk S, Finck C, Flibotte S, Gall B, Galindo-Uribarri A, Haas B, Hackman G, Janzen VP, Kharraja B, Lisle JC, Merdinger JC, Mullins SM, Pilotte S, Prévost D, Radford DC, Rauch V, Rigollet C, Smalley D, Smith MB, Stezowski O, Styczen J, Theisen C, Twin PJ, Vivien JP, Waddington JC, Zuber K, Ragnarsson I. Lifetime measurements of superdeformed bands in 148-149Gd and 152Dy: Evidence for structure-dependent elongations. Phys Rev Lett 1996; 76:4480-4483. [PMID: 10061302 DOI: 10.1103/physrevlett.76.4480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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