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Kamarajah SK, MacLennan G, Pandanaboyana S. Complexity of trials on pain management in acute pancreatitis: an ongoing challenge. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00353-7. [PMID: 38631595 DOI: 10.1016/j.cgh.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Sivesh K Kamarajah
- Department of Global Health and Surgery, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Graeme MacLennan
- The Centre for Healthcare Randomised Trials,Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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2
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Heer R, Tan WS, Gravestock P, Vadiveloo T, Lewis R, Penegar S, Vale L, MacLennan G, Hall E. Reply to Arnulf Stenzl, Morgan Rouprêt, J. Alfred Witjes, Paolo Gontero. High-quality Transurethral Resection of Bladder Tumour Needs Additional Forms of Tumour Delineation. Eur Urol 2023;83:193-4. Eur Urol 2024; 85:309-312. [PMID: 37330372 DOI: 10.1016/j.eururo.2023.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Rakesh Heer
- Division of Surgery, Imperial College London, London, UK.
| | | | - Paul Gravestock
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | | | | | - Luke Vale
- Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
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3
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Long MB, Abo-Leyah H, Giam YH, Vadiveloo T, Hull RC, Keir HR, Pembridge T, Alferes De Lima D, Delgado L, Inglis SK, Hughes C, Gilmour A, Gierlinski M, New BJ, MacLennan G, Dinkova-Kostova AT, Chalmers JD. SFX-01 in hospitalised patients with community-acquired pneumonia during the COVID-19 pandemic: a double-blind, randomised, placebo-controlled trial. ERJ Open Res 2024; 10:00917-2023. [PMID: 38469377 PMCID: PMC10926007 DOI: 10.1183/23120541.00917-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/15/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction Sulforaphane can induce the transcription factor, Nrf2, promoting antioxidant and anti-inflammatory responses. In this study, hospitalised patients with community-acquired pneumonia (CAP) were treated with stabilised synthetic sulforaphane (SFX-01) to evaluate impact on clinical status and inflammation. Methods Double-blind, randomised, placebo-controlled trial of SFX-01 (300 mg oral capsule, once daily for 14 days) conducted in Dundee, UK, between November 2020 and May 2021. Patients had radiologically confirmed CAP and CURB-65 (confusion, urea >7 mmol·L-1, respiratory rate ≥30 breaths·min-1, blood pressure <90 mmHg (systolic) or ≤60 mmHg (diastolic), age ≥65 years) score ≥1. The primary outcome was the seven-point World Health Organization clinical status scale at day 15. Secondary outcomes included time to clinical improvement, length of stay and mortality. Effects on Nrf2 activity and inflammation were evaluated on days 1, 8 and 15 by measurement of 45 serum cytokines and mRNA sequencing of peripheral blood leukocytes. Results The trial was terminated prematurely due to futility with 133 patients enrolled. 65 patients were randomised to SFX-01 treatment and 68 patients to placebo. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was the cause of CAP in 103 (77%) cases. SFX-01 treatment did not improve clinical status at day 15 (adjusted OR 0.87, 95% CI 0.41-1.83; p=0.71), time to clinical improvement (adjusted hazard ratio (aHR) 1.02, 95% CI 0.70-1.49), length of stay (aHR 0.84, 95% CI 0.56-1.26) or 28-day mortality (aHR 1.45, 95% CI 0.67-3.16). The expression of Nrf2 targets and pro-inflammatory genes, including interleukin (IL)-6, IL-1β and tumour necrosis factor-α, was not significantly changed by SFX-01 treatment. At days 8 and 15, respectively, 310 and 42 significant differentially expressed genes were identified between groups (false discovery rate adjusted p<0.05, log2FC >1). Conclusion SFX-01 treatment did not improve clinical status or modulate key Nrf2 targets in patients with CAP primarily due to SARS-CoV-2 infection.
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Affiliation(s)
- Merete B. Long
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- These authors contributed equally
| | - Hani Abo-Leyah
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- These authors contributed equally
| | - Yan Hui Giam
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Rebecca C. Hull
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
| | - Holly R. Keir
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Thomas Pembridge
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Daniela Alferes De Lima
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Lilia Delgado
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Sarah K. Inglis
- Tayside Clinical Trials Unit, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Chloe Hughes
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Amy Gilmour
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Marek Gierlinski
- Computational Biology, School of Life Sciences, University of Dundee, Dundee, UK
| | | | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Albena T. Dinkova-Kostova
- Division of Cellular and Systems Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- Department of Pharmacology and Molecular Sciences and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James D. Chalmers
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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4
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Kilonzo M, Boyers D, Cooper D, Davidson T, Bhal K, N'Dow J, MacLennan G, Norrie J, Abdel‐Fattah M. Three-year cost utility analysis of mini versus standard slings: A trial based economic evaluation. BJUI Compass 2024; 5:230-239. [PMID: 38371196 PMCID: PMC10869650 DOI: 10.1002/bco2.303] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/08/2023] [Accepted: 09/26/2023] [Indexed: 02/20/2024] Open
Abstract
Objective To report on the cost-effectiveness of adjustable anchored single-incision mini-slings (mini-slings) compared with tension-free standard mid-urethral slings (standard slings) in the surgical management of female stress urinary incontinence (SUI). Patients and Methods Data on resource use and quality were collected from women aged ≥18 years with predominant SUI undergoing mid-urethral sling procedures in 21 UK hospitals. Resource use and quality of life (QoL) data were prospectively collected alongside the Single-Incision Mini-Slings versus standard synthetic mid-urethral slings Randomised Control Trial (SIMS RCT), for surgical treatment of SUI in women. A health service provider's (National Health Service [NHS]) perspective with 3-year follow-up was adopted to estimate the costs of the intervention and all subsequent resource use. A generic instrument, EuroQol EQ-5D-3L, was used to estimate the QoL. Results are reported as incremental costs, quality adjusted life years (QALYs) and incremental cost per QALY. Results Base case analysis results show that although mini-slings cost less, there was no significant difference in costs: mini-slings versus standard slings: £-6 [95% CI -228-208] or in QALYs: 0.005 [95% CI -0.068-0.073] over the 3-year follow-up. There is substantial uncertainty, with a 56% and 44% probability that mini-slings and standard slings are the most cost-effective treatment, respectively, at a £20 000 willingness-to-pay threshold value for a QALY. Conclusions At 3 years, there is no significant difference between mini-slings and standard slings in costs and QALYs. There is still some uncertainty over the long-term complications and failure rates of the devices used in the treatment of SUI; therefore, it is important to establish the long-term clinical and cost-effectiveness of these procedures.
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Affiliation(s)
- Mary Kilonzo
- Health Economics Research UnitUniversity of AberdeenAberdeenUK
| | - Dwayne Boyers
- Health Economics Research UnitUniversity of AberdeenAberdeenUK
| | - David Cooper
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | - Tracey Davidson
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | - Kiron Bhal
- Department of UrogynaecologyUniversity Hospital of WalesCardiffWalesUK
| | - James N'Dow
- Academic Urology UnitUniversity of AberdeenAberdeenUK
| | - Graeme MacLennan
- The Centre for Healthcare Randomised TrialsUniversity of AberdeenAberdeenUK
| | - John Norrie
- Usher Institute Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
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5
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King AJ, Hudson J, Azuara-Blanco A, Burr J, Kernohan A, Homer T, Shabaninejad H, Sparrow JM, Garway-Heath D, Barton K, Norrie J, Davidson T, Vale L, MacLennan G. Evaluating Primary Treatment for People with Advanced Glaucoma: Five-Year Results of the Treatment of Advanced Glaucoma Study. Ophthalmology 2024:S0161-6420(24)00016-2. [PMID: 38199528 DOI: 10.1016/j.ophtha.2024.01.007] [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: 08/23/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024] Open
Abstract
PURPOSE To determine whether primary trabeculectomy or medical treatment produces better outcomes in terms of quality of life (QoL), clinical effectiveness, and safety in patients with advanced glaucoma. DESIGN Multicenter randomized controlled trial. PARTICIPANTS Between June 3, 2014, and May 31, 2017, 453 adults with newly diagnosed advanced open-angle glaucoma in at least 1 eye (Hodapp classification) were recruited from 27 secondary care glaucoma departments in the United Kingdom. Two hundred twenty-seven were allocated to trabeculectomy, and 226 were allocated medical management. METHODS Participants were randomized on a 1:1 basis to have either mitomycin C-augmented trabeculectomy or escalating medical management with intraocular pressure (IOP)-reducing drops as the primary intervention and were followed up for 5 years. MAIN OUTCOME MEASURES The primary outcome was vision-specific QoL measured with the 25-item Visual Function Questionnaire (VFQ-25) at 5 years. Secondary outcomes were general health status, glaucoma-related QoL, clinical effectiveness (IOP, visual field, and visual acuity), and safety. RESULTS At 5 years, the mean ± standard deviation VFQ-25 scores in the trabeculectomy and medication arms were 83.3 ± 15.5 and 81.3 ± 17.5, respectively, and the mean difference was 1.01 (95% confidence interval [CI], -1.99 to 4.00; P = 0.51). The mean IOPs were 12.07 ± 5.18 mmHg and 14.76 ± 4.14 mmHg, respectively, and the mean difference was -2.56 (95% CI, -3.80 to -1.32; P < 0.001). Glaucoma severity measured with visual field mean deviation were -14.30 ± 7.14 dB and -16.74 ± 6.78 dB, respectively, with a mean difference of 1.87 (95% CI, 0.87-2.87 dB; P < 0.001). Safety events occurred in 115 (52.2%) of patients in the trabeculectomy arm and 124 (57.9%) of patients in the medication arm (relative risk, 0.92; 95% CI, 0.72-1.19; P = 0.54). Serious adverse events were rare. CONCLUSIONS At 5 years, the Treatment of Advanced Glaucoma Study demonstrated that primary trabeculectomy surgery is more effective in lowering IOP and preventing disease progression than primary medical treatment in patients with advanced disease and has a similar safety profile. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Anthony J King
- Nottingham University Hospital, Nottingham, United Kingdom.
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Augusto Azuara-Blanco
- Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital, Belfast, United Kingdom
| | - Jennifer Burr
- School of Medicine, University of St. Andrews, St. Andrews, United Kingdom
| | - Ashleigh Kernohan
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tara Homer
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hosein Shabaninejad
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John M Sparrow
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - David Garway-Heath
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Keith Barton
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Tracey Davidson
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
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6
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Clement C, Coulman K, Heywood N, Pinkney T, Blazeby J, Blencowe NS, Cook JA, Bulbulia R, Arenas-Pinto A, Snowdon C, Hilton Z, Magill L, MacLennan G, Glasbey J, Nepogodiev D, Hardy V, Lane JA. How surgical Trainee Research Collaboratives achieve success: a mixed methods study to develop trainee engagement strategies. BMJ Open 2023; 13:e072851. [PMID: 38072493 PMCID: PMC10729246 DOI: 10.1136/bmjopen-2023-072851] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES This study aimed to understand the role of surgical Trainee Research Collaboratives (TRCs) in conducting randomised controlled trials and identify strategies to enhance trainee engagement in trials. DESIGN This is a mixed methods study. We used observation of TRC meetings, semi-structured interviews and an online survey to explore trainees' motivations for engagement in trials and TRCs, including barriers and facilitators. Interviews were analysed thematically, alongside observation field notes. Survey responses were analysed using descriptive statistics. Strategies to enhance TRCs were developed at a workshop by 13 trial methodologists, surgical trainees, consultants and research nurses. SETTING This study was conducted within a secondary care setting in the UK. PARTICIPANTS The survey was sent to registered UK surgical trainees. TRC members and linked stakeholders across surgical specialties and UK regions were purposefully sampled for interviews. RESULTS We observed 5 TRC meetings, conducted 32 semi-structured interviews and analysed 73 survey responses. TRCs can mobilise trainees thus gaining wider access to patients. Trainees engaged with TRCs to improve patient care, surgical evidence and to help progress their careers. Trainees valued the TRC infrastructure, research expertise and mentoring. Challenges for trainees included clinical and other priorities, limited time and confidence, and recognition, especially by authorship. Key TRC strategies were consultant support, initial simple rapid studies, transparency of involvement and recognition for trainees (including authorship policies) and working with Clinical Trials Units and research nurses. A 6 min digital story on YouTube disseminated these strategies. CONCLUSION Trainee surgeons are mostly motivated to engage with trials and TRCs. Trainee engagement in TRCs can be enhanced through building relationships with key stakeholders, maximising multi-disciplinary working and offering training and career development opportunities.
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Affiliation(s)
- Clare Clement
- Bristol Trials Centre, University of Bristol, Bristol, UK
- Centre for Appearance Research, University of West England (UWE Bristol), Bristol, UK
| | - Karen Coulman
- Bristol Centre for Surgical Research and Bristol Biomedical Research Centre, University of Bristol Medical School, Bristol, UK
| | - Nick Heywood
- Department of General Surgery Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tom Pinkney
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research and Bristol Biomedical Research Centre, University of Bristol Medical School, Bristol, UK
| | - Natalie S Blencowe
- Bristol Centre for Surgical Research and Bristol Biomedical Research Centre, University of Bristol Medical School, Bristol, UK
| | - Jonathan Alistair Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Claire Snowdon
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Zoe Hilton
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Laura Magill
- University of Birmingham Clinical Trials Unit, Birmingham, UK
| | - Graeme MacLennan
- The Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - James Glasbey
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Victoria Hardy
- National Institute for Social Care and Health Research, Cardiff, UK
| | - J Athene Lane
- Bristol Trials Centre, University of Bristol, Bristol, UK
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7
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Ahmed I, Hudson J, Innes K, Hernández R, Gillies K, Bruce R, Bell V, Avenell A, Blazeby J, Brazzelli M, Cotton S, Croal B, Forrest M, MacLennan G, Murchie P, Wileman S, Ramsay C. Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial. BMJ 2023; 383:e075383. [PMID: 38084426 PMCID: PMC10698555 DOI: 10.1136/bmj-2023-075383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE To assess the clinical and cost effectiveness of conservative management compared with laparoscopic cholecystectomy for the prevention of symptoms and complications in adults with uncomplicated symptomatic gallstone disease. DESIGN Parallel group, pragmatic randomised, superiority trial. SETTING 20 secondary care centres in the UK. PARTICIPANTS 434 adults (>18 years) with uncomplicated symptomatic gallstone disease referred to secondary care, assessed for eligibility between August 2016 and November 2019, and randomly assigned (1:1) to receive conservative management or laparoscopic cholecystectomy. INTERVENTIONS Conservative management or surgical removal of the gallbladder. MAIN OUTCOME MEASURES The primary patient outcome was quality of life, measured by area under the curve, over 18 months using the short form 36 (SF-36) bodily pain domain, with higher scores (range 0-100) indicating better quality of life. Other outcomes included costs to the NHS, quality adjusted life years (QALYs), and incremental cost effectiveness ratio. RESULTS Of 2667 patients assessed for eligibility, 434 were randomised: 217 to the conservative management group and 217 to the laparoscopic cholecystectomy group. By 18 months, 54 (25%) participants in the conservative management arm and 146 (67%) in the cholecystectomy arm had received surgery. The mean SF-36 norm based bodily pain score was 49.4 (standard deviation 11.7) in the conservative management arm and 50.4 (11.6) in the cholecystectomy arm. The SF-36 bodily pain area under the curve up to 18 months did not differ (mean difference 0.0, 95% confidence interval -1.7 to 1.7; P=1.00). Conservative management was less costly (mean difference -£1033, (-$1334; -€1205), 95% credible interval -£1413 to -£632) and QALYs did not differ (mean difference -0.019, 95% credible interval -0.06 to 0.02). CONCLUSIONS In the short term (≤18 months), laparoscopic surgery is no more effective than conservative management for adults with uncomplicated symptomatic gallstone disease, and as such conservative management should be considered as an alternative to surgery. From an NHS perspective, conservative management may be cost effective for uncomplicated symptomatic gallstone disease. As costs, complications, and benefits will continue to be incurred in both groups beyond 18 months, future research should focus on longer term follow-up to establish effectiveness and lifetime cost effectiveness and to identify the cohort of patients who should be routinely offered surgery. TRIAL REGISTRATION ISRCTN registry ISRCTN55215960.
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Affiliation(s)
- Irfan Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Karen Innes
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Bruce
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Bell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jane Blazeby
- Centre for Surgical Research, NIHR Bristol and Western Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- The Centre for Healthcare Randomised Trials,Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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8
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Chong HY, McNamee P, Bachmair EM, Martin K, Aucott L, Dhaun N, Dures E, Emsley R, Gray SR, Kidd E, Kumar V, Lovell K, MacLennan G, Norrie J, Paul L, Packham J, Ralston SH, Siebert S, Wearden A, Macfarlane G, Basu N. Cost-effectiveness of cognitive behavioural and personalized exercise interventions for reducing fatigue in inflammatory rheumatic diseases. Rheumatology (Oxford) 2023; 62:3819-3827. [PMID: 37018151 PMCID: PMC10691924 DOI: 10.1093/rheumatology/kead157] [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: 09/07/2022] [Revised: 02/09/2023] [Accepted: 02/27/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES To estimate the cost-effectiveness of a cognitive behavioural approach (CBA) or a personalized exercise programme (PEP), alongside usual care (UC), in patients with inflammatory rheumatic diseases who report chronic, moderate to severe fatigue. METHODS A within-trial cost-utility analysis was conducted using individual patient data collected within a multicentre, three-arm randomized controlled trial over a 56-week period. The primary economic analysis was conducted from the UK National Health Service (NHS) perspective. Uncertainty was explored using cost-effectiveness acceptability curves and sensitivity analysis. RESULTS Complete-case analysis showed that, compared with UC, both PEP and CBA were more expensive [adjusted mean cost difference: PEP £569 (95% CI: £464, £665); CBA £845 (95% CI: £717, £993)] and, in the case of PEP, significantly more effective [adjusted mean quality-adjusted life year (QALY) difference: PEP 0.043 (95% CI: 0.019, 0.068); CBA 0.001 (95% CI: -0.022, 0.022)]. These led to an incremental cost-effectiveness ratio (ICER) of £13 159 for PEP vs UC, and £793 777 for CBA vs UC. Non-parametric bootstrapping showed that, at a threshold value of £20 000 per QALY gained, PEP had a probability of 88% of being cost-effective. In multiple imputation analysis, PEP was associated with significant incremental costs of £428 (95% CI: £324, £511) and a non-significant QALY gain of 0.016 (95% CI: -0.003, 0.035), leading to an ICER of £26 822 vs UC. The estimates from sensitivity analyses were consistent with these results. CONCLUSION The addition of a PEP alongside UC is likely to provide a cost-effective use of health care resources.
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Affiliation(s)
- Huey Yi Chong
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Paul McNamee
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Eva-Maria Bachmair
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen, UK
| | - Kathryn Martin
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Academic Primary Care Group), University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Centre of Healthcare and Randomised Trials (CHaRT), Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh/British Heart Foundation Centre of Research Excellence, Edinburgh, UK
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Elizabeth Kidd
- Department of Rheumatology, Freeman’s Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vinod Kumar
- Department of Rheumatology, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Karina Lovell
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Centre of Healthcare and Randomised Trials (CHaRT), Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Lorna Paul
- School of Health and Life Science, Glasgow Caledonian University, Glasgow, UK
| | - Jonathan Packham
- Physiotherapy and Paramedicine, Haywood Rheumatology Centre, Stoke-on-Trent, UK
| | - Stuart H Ralston
- Rheumatology and Bone Disease, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Alison Wearden
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Gary Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Academic Primary Care Group), University of Aberdeen, Aberdeen, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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9
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Jansen JO, Hudson J, Cochran C, MacLennan G, Lendrum R, Sadek S, Gillies K, Cotton S, Kennedy C, Boyers D, Ferry G, Lawrie L, Nath M, Wileman S, Forrest M, Brohi K, Harris T, Lecky F, Moran C, Morrison JJ, Norrie J, Paterson A, Tai N, Welch N, Campbell MK. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA 2023; 330:1862-1871. [PMID: 37824132 PMCID: PMC10570916 DOI: 10.1001/jama.2023.20850] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/23/2023] [Indexed: 10/13/2023]
Abstract
Importance Bleeding is the most common cause of preventable death after trauma. Objective To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage. Design, Setting, and Participants Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days. Intervention Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44). Main Outcomes and Measures The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death. Results Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours. Conclusions and Relevance In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone. Trial Registration isrctn.org Identifier: ISRCTN16184981.
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Affiliation(s)
- Jan O. Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
- Center for Injury Science, University of Alabama at Birmingham
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Sam Sadek
- Royal London Hospital, London, England
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Gillian Ferry
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mintu Nath
- Medical Statistics Team, University of Aberdeen, Aberdeen, Scotland
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Karim Brohi
- Queen Mary University of London, London, England
| | - Tim Harris
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Chris Moran
- Nottingham University Hospital Trust, Nottingham, England
| | - Jonathan J. Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland
| | | | - Nigel Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England
| | - Nick Welch
- Patient and public involvement representative in England
| | - Marion K. Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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10
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Berry K, Matheson C, Schofield J, Dumbrell J, Parkes T, Hill D, Kilonzo M, MacLennan G, Stewart D, Ritchie T, Turner M. Development of an intervention to manage benzodiazepine dependence and high-risk use in the context of escalating drug related deaths in Scotland: an application of the MRC framework. BMC Health Serv Res 2023; 23:1205. [PMID: 37925423 PMCID: PMC10625279 DOI: 10.1186/s12913-023-10201-7] [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: 05/15/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Scotland has the highest rate of drug related deaths (DRD) in Europe. These are deaths in people who use drugs such as heroin, cocaine, benzodiazepines and gabapentinoids. It is a feature of deaths in Scotland that people use combinations of drugs which increases the chance of a DRD. Many deaths involve 'street' benzodiazepines, especially a drug called etizolam. Many of the 'street' benzodiazepines are not licensed in the UK so come from illegal sources. People who use opiates can be prescribed a safer replacement medication (e.g., methadone). While guidance on management of benzodiazepines use highlights that there is little evidence to support replacement prescribing, practice and evidence are emerging. AIM To develop an intervention to address 'street' benzodiazepines use in people who also use opiates. METHODS The MRC Framework for Complex Interventions was used to inform research design. Co-production of the intervention was achieved through three online workshops with clinicians, academics working in the area of substance use, and people with lived experience (PWLE). Each workshop was followed by a PWLE group meeting. Outputs from workshops were discussed and refined by the PWLE group and then further explored at the next workshop. RESULTS After these six sessions, a finalised logic model for the intervention was successfully achieved that was acceptable to clinicians and PWLE. Key components of the intervention were: prescribing of diazepam; anxiety management, sleep, and pain; and harm reduction resources (locked box and a range of tips), personal safety conversations, as well as a virtual learning environment. CONCLUSION A co-produced intervention was developed for next stage clinical feasibility testing.
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Grants
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
- HIPS/20/09 Chief Scientist Office, Scottish Government Health and Social Care Directorate
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11
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Goughenour A, Kebede B, MacLennan G, Castro J, Stephenson L, Majithia L, Hetelekidis S, Parniani A, Fan J, Wang P, Chawla AK, Rao AD. Dosimetric and Clinical Results of a Volumetric-Based Skin-Sparing Planning Technique for Patients Treated to the Breast and Chest Wall with Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2023; 117:S89-S90. [PMID: 37784598 DOI: 10.1016/j.ijrobp.2023.06.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Given clinical concerns for more brisk acute skin toxicity with proton compared with photon RT due to differences in the energy deposition properties, our institution implemented a novel volumetric skin-sparing planning technique (SSPT) for intensity modulated proton therapy (IMPT) for patients treated to the breast or chest wall (CW). This study evaluates SSPT dosimetry and the hypothesis that a SSPT will reduce acute dermatitis during IMPT to the breast and CW. MATERIALS/METHODS Prior to the development of a consensus technique, skin dose evaluation in IMPT plans was limited to mitigation of skin hot spots and cropping off the skin surface by 3mm for CW and 5mm for intact breast targets (except indications for deliberate skin dosing). In January 2022 our center added volumetric-based skin sparing objectives in addition to hot-spot evaluation as a SSPT. A skin evaluation structure (skin-eval) was defined as a skin rind of 3 mm for CW and 5 mm for intact breast within 5mm of the CTV, bound by the patient's surface. The SSPT incorporated an objective to limit the volume of skin-eval receiving 95% of the prescription dose or more (V95%Rx) to ideally <50% (goal<60%) while still prioritizing CTV coverage and robustness. We compared target coverage, robustness, and skin-eval dosimetry as well as acute on-treatment skin toxicity in patients treated with and without incorporation of this SSPT. Patients with skin/dermal lymphatic invasion or inflammatory breast cancer were excluded. RESULTS 84 patients who were planned to receive breast or CW IMPT were included (43 planned without and 41 with the SSPT). There was no difference in percentages of patients treated to the intact breast/CW/immediate CW reconstruction between the groups (37%/23%/40% without and 34%/27%/39% with SSPT, p>0.05). Mean skin-evalV95%Rx was 72% vs. 30%, p<0.0001, for those treated without vs. with a SSPT. Maximum %Rx to the skin volume of 0.03 cc, 0.3cc, and 1cc, was higher in patients treated without compared to those with a SSPT (103.1% vs. 101.5%; 101.3% vs. 100.4%; and 101.8% vs. 99.7% (all p=<0.0001)), respectively. There was a small statistical difference in the mean CTV V97.5%Rx in patients treated without vs. with the SSPT (97.8% vs. 96.5%, p=0.0003). Patients planned utilizing the SSPT demonstrated reduced rates of Grade 1 breast pain at Week 2 (12% vs. 33%, p=0.0424) and Grade 2 and 3 dermatitis at Week 5 (grade 2 38% vs. 42%; grade 3, 0% vs. 11%, p=0.0016). There were numerically more patients requiring a treatment break or not completing full intended prescription (4 vs. 1) in the pre-SSPT cohort. CONCLUSION A volumetric-based SSPT appears to reduce the frequency of brisk onset dermatitis and near-end of RT significant dermatitis while still maintaining acceptable target coverage and robustness in patients receiving IMPT to the breast and CW.
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Affiliation(s)
| | - B Kebede
- Inova Schar Cancer Institute, Fairfax, VA
| | | | - J Castro
- Inova Schar Cancer Institute, Fairfax, VA
| | | | - L Majithia
- Inova Schar Cancer Institute, Fairfax, VA; Radiation Oncology Associates of the National Capital Region, Fairfax, VA
| | - S Hetelekidis
- Inova Schar Cancer Institute, Fairfax, VA; Radiation Oncology Associates of the National Capital Region, Fairfax, VA
| | - A Parniani
- Inova Schar Cancer Institute, Fairfax, VA
| | - J Fan
- Inova Schar Cancer Institute, Fairfax, VA
| | - P Wang
- Inova Schar Cancer Institute, Fairfax, VA
| | - A K Chawla
- Inova Schar Cancer Institute, Fairfax, VA; Radiation Oncology Associates of the National Capital Region, Fairfax, VA
| | - A D Rao
- Inova Schar Cancer Institute, Fairfax, VA; Radiation Oncology Associates of the National Capital Region, Fairfax, VA
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12
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Boyers D, Kilonzo M, Davidson T, Cooper D, Wardle J, Bhal K, N'Dow J, MacLennan G, Norrie J, Abdel-Fattah M. Patient preferences for stress urinary incontinence treatments: a discrete choice experiment. BMJ Open 2023; 13:e066157. [PMID: 37643846 PMCID: PMC10465896 DOI: 10.1136/bmjopen-2022-066157] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 04/28/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To elicit and value patient preferences for the processes and outcomes of surgical management of stress urinary incontinence in women. DESIGN A discrete choice experiment survey to elicit preferences for type of anaesthesia, postoperative recovery time, treatment success, adverse events, impact on daily activities and cost. An experimental design generated 40 choice tasks, and each respondent completed 1 block of 10 and 2 validity tests. Analysis was by multinomial logistical regression. SETTING N=21 UK hospitals. PARTICIPANTS N=325 adult women who were a subsample of those randomised to the single-incision mini-slings clinical trial. OUTCOMES Patient preferences; valuation obtained using willingness to pay. RESULTS N=227 of 325 (70%) returned a questionnaire, and 94% of those completed all choice tasks. Respondents preferred general anaesthesia, shorter recovery times, improved stress urinary incontinence symptoms and avoidance of adverse events. Women were willing to pay (mean (95% CI)) £76 (£33 to £119) per day of reduction in recovery time following surgery. They valued increases in Patient Global Impression of Improvement, ranging from £8173 (£5459 to £10 887) for 'improved' to £11 706 (£8267 to £15 144) for 'very much improved' symptoms, compared with no symptom improvement. This was offset by negative values attached to the avoidance of complications ranging between £-8022 (£-10 661 to £-5383) and £-10 632 (£-14 077 to £-7187) compared to no complications. Women valued treatments that reduced the need to avoid daily activities, with willingness to pay ranging from £-967 (£-2199 to £266) for rarely avoiding activities to £-5338 (£-7258 to £-3417) for frequently avoiding daily activities compared with no avoidance. CONCLUSION This discrete choice experiment demonstrates that patients place considerable value on improvement in stress urinary incontinence symptoms and avoidance of treatment complications. Trade-offs between symptom improvement and adverse event risk should be considered within shared decision-making. The willingness to pay values from this study can be used in future cost-benefit analyses. TRIAL REGISTRATION NUMBER ISRCTN: 93264234; Post-results.
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Affiliation(s)
- Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Tracey Davidson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Kiron Bhal
- University Hospital of Wales, Cardiff, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh No 9 Bioquarter, Edinburgh, UK
| | - Mohamed Abdel-Fattah
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
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13
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Kilonzo MM, Dasgupta R, Thomas R, Aucott L, MacLennan S, Lam TBL, Anson K, Cameron S, Starr K, Burgess N, Keeley FX, Clark CT, N'Dow J, MacLennan G, McClinton S. Cost-utility analysis of shockwave lithotripsy vs ureteroscopic stone treatment in adults. BJU Int 2023; 131:253-261. [PMID: 35974700 PMCID: PMC10087721 DOI: 10.1111/bju.15862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness, resource use implications, quality-adjusted life-years (QALYs) and cost per QALY of care pathways starting with either extracorporeal shockwave lithotripsy (SWL) or with ureteroscopic retrieval (ureteroscopy [URS]) for the management of ureteric stones. PATIENTS AND METHODS Data on quality of life and resource use for 613 patients, collected prospectively in the Therapeutic Interventions for Stones of the Ureter (TISU) randomized controlled trial (ISRCTN 92289221), were used to assess the cost-effectiveness of two care pathways, SWL and URS. A health provider (UK National Health Service) perspective was adopted to estimate the costs of the interventions and subsequent resource use. Quality-of-life data were calculated using a generic instrument, the EuroQol EQ-5D-3L. Results are expressed as incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. RESULTS The mean QALY difference (SWL vs URS) was -0.021 (95% confidence interval [CI] -0.033 to -0.010) and the mean cost difference was -£809 (95% CI -£1061 to -£551). The QALY difference translated into approximately 10 more healthy days over the 6-month period for the patients on the URS care pathway. The probabaility that SWL is cost-effective is 79% at a society's willingness to pay (WTP) threshold for 1 QALY of £30,000 and 98% at a WTP threshold of £20,000. CONCLUSION The SWL pathway results in lower QALYs than URS but costs less. The incremental cost per QALY is £39 118 cost saving per QALY lost, with a 79% probability that SWL would be considered cost-effective at a WTP threshold for 1 QALY of £30 000 and 98% at a WTP threshold of £20 000. Decision-makers need to determine if costs saved justify the loss in QALYs.
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Affiliation(s)
- Mary M Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Ruth Thomas
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sara MacLennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Thomas Boon L Lam
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ken Anson
- Department of Urology, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Kath Starr
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Neil Burgess
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | - Charles T Clark
- BAUS Section of Endourology Consumer/Patient Advisory Group, London, UK
| | - James N'Dow
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Sam McClinton
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
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14
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Reid FM, Aucott L, Glazener CMA, Elders A, Hemming C, Cooper KG, Freeman RM, Smith ARB, Hagen S, Kilonzo M, Boyers D, MacLennan G, Norrie J, Breeman S. PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse. Int Urogynecol J 2023; 34:67-78. [PMID: 36018353 PMCID: PMC9834125 DOI: 10.1007/s00192-022-05308-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/24/2022] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to compare the mid-term results of native tissue, biological xenograft and polypropylene mesh surgery for women with vaginal wall prolapse. METHODS A total of 1348 women undergoing primary transvaginal repair of an anterior and/or posterior prolapse were recruited between January 2010 and August 2013 from 35 UK centres. They were randomised by remote allocation to native tissue surgery, biological xenograft or polypropylene mesh. We performed both 4- and 6-year follow-up using validated patient-reported outcome measures. RESULTS At 4 and 6 years post-operation, there was no clinically important difference in Pelvic Organ Prolapse Symptom Score for any of the treatments. Using a strict composite outcome to assess functional cure at 6 years, we found no difference in cure among the three types of surgery. Half the women were cured at 6 years but only 10.3 to 12% of women had undergone further surgery for prolapse. However, 8.4% of women in the mesh group had undergone further surgery for mesh complications. There was no difference in the incidence of chronic pain or dyspareunia between groups. CONCLUSIONS At the mid-term outcome of 6 years, there is no benefit from augmenting primary prolapse repairs with polypropylene mesh inlays or biological xenografts. There was no evidence that polypropylene mesh inlays caused greater pain or dyspareunia than native tissue repairs.
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Affiliation(s)
- Fiona M Reid
- Warrell Unit, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road Campus, Manchester, M13 0JH, UK.
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Christine Hemming
- Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kevin G Cooper
- Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Robert M Freeman
- Department of Obstetrics and Gynaecology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Anthony R B Smith
- Warrell Unit, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road Campus, Manchester, M13 0JH, UK
| | - Suzanne Hagen
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher institute, University of Edinburgh, Edinburgh, UK
| | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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15
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Keir HR, Long MB, Abo-Leyah H, Giam YH, Vadiveloo T, Pembridge T, Hull RC, Delgado L, Band M, McLaren-Neil F, Adamson S, Lahnsteiner E, Gilmour A, Hughes C, New BJ, Connell D, Dowey R, Turton H, Richardson H, Cassidy D, Cooper J, Suntharalingam J, Diwakar L, Russell P, Underwood J, Hicks A, Dosanjh DP, Sage B, Dhasmana D, Spears M, Thompson AR, Brightling C, Smith A, Patel M, George J, Condliffe AM, Shoemark A, MacLennan G, Chalmers JD. Dipeptidyl peptidase-1 inhibition in patients hospitalised with COVID-19: a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial. Lancet Respir Med 2022; 10:1119-1128. [PMID: 36075243 PMCID: PMC9442496 DOI: 10.1016/s2213-2600(22)00261-2] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neutrophil serine proteases are involved in the pathogenesis of COVID-19 and increased serine protease activity has been reported in severe and fatal infection. We investigated whether brensocatib, an inhibitor of dipeptidyl peptidase-1 (DPP-1; an enzyme responsible for the activation of neutrophil serine proteases), would improve outcomes in patients hospitalised with COVID-19. METHODS In a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial, across 14 hospitals in the UK, patients aged 16 years and older who were hospitalised with COVID-19 and had at least one risk factor for severe disease were randomly assigned 1:1, within 96 h of hospital admission, to once-daily brensocatib 25 mg or placebo orally for 28 days. Patients were randomly assigned via a central web-based randomisation system (TruST). Randomisation was stratified by site and age (65 years or ≥65 years), and within each stratum, blocks were of random sizes of two, four, or six patients. Participants in both groups continued to receive other therapies required to manage their condition. Participants, study staff, and investigators were masked to the study assignment. The primary outcome was the 7-point WHO ordinal scale for clinical status at day 29 after random assignment. The intention-to-treat population included all patients who were randomly assigned and met the enrolment criteria. The safety population included all participants who received at least one dose of study medication. This study was registered with the ISRCTN registry, ISRCTN30564012. FINDINGS Between June 5, 2020, and Jan 25, 2021, 406 patients were randomly assigned to brensocatib or placebo; 192 (47·3%) to the brensocatib group and 214 (52·7%) to the placebo group. Two participants were excluded after being randomly assigned in the brensocatib group (214 patients included in the placebo group and 190 included in the brensocatib group in the intention-to-treat population). Primary outcome data was unavailable for six patients (three in the brensocatib group and three in the placebo group). Patients in the brensocatib group had worse clinical status at day 29 after being randomly assigned than those in the placebo group (adjusted odds ratio 0·72 [95% CI 0·57-0·92]). Prespecified subgroup analyses of the primary outcome supported the primary results. 185 participants reported at least one adverse event; 99 (46%) in the placebo group and 86 (45%) in the brensocatib group. The most common adverse events were gastrointestinal disorders and infections. One death in the placebo group was judged as possibly related to study drug. INTERPRETATION Brensocatib treatment did not improve clinical status at day 29 in patients hospitalised with COVID-19. FUNDING Sponsored by the University of Dundee and supported through an Investigator Initiated Research award from Insmed, Bridgewater, NJ; STOP-COVID19 trial.
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Affiliation(s)
- Holly R Keir
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Merete B Long
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Hani Abo-Leyah
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Yan Hui Giam
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Thomas Pembridge
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Rebecca C Hull
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Lilia Delgado
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Margaret Band
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Simon Adamson
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Eva Lahnsteiner
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Amy Gilmour
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Chloe Hughes
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Benjamin Jm New
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - David Connell
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Rebecca Dowey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Helena Turton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Diane Cassidy
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | | | | | | | | | | | | | | | | | - Mark Spears
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Aa Roger Thompson
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | | | | | - Jacob George
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Alison M Condliffe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Amelia Shoemark
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - James D Chalmers
- Molecular and Clinical Medicine, University of Dundee, Dundee, UK.
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Abdel-Fattah M, Cooper D, Davidson T, Kilonzo M, Boyers D, Bhal K, McDonald A, Wardle J, N'Dow J, MacLennan G, Norrie J. Single-incision mini-slings versus standard synthetic mid-urethral slings for surgical treatment of stress urinary incontinence in women: The SIMS RCT. Health Technol Assess 2022; 26:1-190. [PMID: 36520097 PMCID: PMC9761550 DOI: 10.3310/btsa6148] [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] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Stress urinary incontinence is the most common type of urinary incontinence in premenopausal women. Until recently, synthetic mid-urethral slings (mesh/tape) were the standard surgical treatment, if conservative management failed. Adjustable anchored single-incision mini-slings are newer, use less mesh and may reduce perioperative morbidity, but it is unclear how their success rates and safety compare with those of standard tension-free mid-urethral slings. OBJECTIVE The objective was to compare tension-free standard mid-urethral slings with adjustable anchored single-incision mini-slings among women with stress urinary incontinence requiring surgical intervention, in terms of patient-reported effectiveness, health-related quality of life, safety and cost-effectiveness. DESIGN This was a pragmatic non-inferiority randomised controlled trial. Allocation was by remote web-based randomisation (1 : 1 ratio). SETTING The trial was set in 21 UK hospitals. PARTICIPANTS Participants were women aged ≥ 18 years with predominant stress urinary incontinence, undergoing a mid-urethral sling procedure. INTERVENTIONS Single-incision mini-slings, compared with standard mid-urethral slings. MAIN OUTCOME MEASURES The primary outcome was patient-reported success rates on the Patient Global Impression of Improvement scale at 15 months post randomisation (≈ 1 year post surgery), with success defined as outcomes of 'very much improved' or 'much improved'. The primary economic outcome was incremental cost per quality-adjusted life-year gained. Secondary outcomes were adverse events, impact on other urinary symptoms, quality of life and sexual function. RESULTS A total of 600 participants were randomised. At 15 months post randomisation, adjustable anchored single-incision mini-slings were non-inferior to tension-free standard mid-urethral slings at the 10% margin for the primary outcome [single-incision mini-sling 79% (212/268) vs. standard mid-urethral sling 76% (189/250), risk difference 4.6, 95% confidence interval -2.7 to 11.8; p non-inferiority < 0.001]. Similarly, at 3 years' follow-up, patient-reported success rates in the single-incision mini-sling group were non-inferior to those of the standard mid-urethral sling group at the 10% margin [single-incision mini-sling 72% (177/246) vs. standard mid-urethral sling 67% (157/235), risk difference 5.7, 95% confidence interval -1.3 to 12.8; p non-inferiority < 0.001]. Tape/mesh exposure rates were higher for single-incision mini-sling participants, with 3.3% (9/276) [compared with 1.9% (5/261) in the standard mid-urethral sling group] reporting tape exposure over the 3 years of follow-up. The rate of groin/thigh pain was slightly higher in the single-incision mini-sling group at 15 months [single-incision mini-sling 15% (41/276) vs. standard mid-urethral sling 12% (31/261), risk difference 3.0%, 95% confidence interval -1.1% to 7.1%]; however, by 3 years, the rate of pain was slightly higher among the standard mid-urethral sling participants [single-incision mini-sling 14% (39/276) vs. standard mid-urethral sling 15% (39/261), risk difference -0.8, 95% confidence interval -4.1 to 2.5]. At the 3-year follow-up, quality of life and sexual function outcomes were similar in both groups: for the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life, the mean difference in scores was -1.1 (95% confidence interval -3.1 to 0.8; p = 0.24), and for the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised, it was 0 (95% confidence interval -0.1, 0.1; p = 0.92). However, more women in the single-incision mini-sling group reported dyspareunia [12% (17/145), compared with 4.8% (7/145) in the standard mid-urethral sling group, risk difference 7.0%, 95% confidence interval 1.9% to 12.1%]. The base-case economics results showed no difference in costs (-£6, 95% confidence interval -£228 to £208) or quality-adjusted life-years (0.005, 95% confidence interval -0.068 to 0.073) between the groups. There is a 56% probability that single-incision mini-slings will be considered cost-effective at the £20,000 willingness-to-pay threshold value for a quality-adjusted life-year. LIMITATIONS Follow-up data beyond 3 years post randomisation are not available to inform longer-term safety and cost-effectiveness. CONCLUSIONS Single-incision mini-slings were non-inferior to standard mid-urethral slings in patient-reported success rates at up to 3 years' follow-up. FUTURE WORK Success rates, adverse events, retreatment rates, symptoms, and quality-of-life scores at 10 years' follow-up will help inform long-term effectiveness. TRIAL REGISTRATION This trial was registered as ISRCTN93264234. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 47. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Mohamed Abdel-Fattah
- Aberdeen Centre For Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Tracey Davidson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kiron Bhal
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Alison McDonald
- Aberdeen Centre For Women's Health Research, University of Aberdeen, Aberdeen, UK
| | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Aberdeen Centre For Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
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Khadhouri S, Gallagher KM, MacKenzie KR, Shah TT, Gao C, Moore S, Zimmermann EF, Edison E, Jefferies M, Nambiar A, Anbarasan T, Mannas MP, Lee T, Marra G, Gómez Rivas J, Marcq G, Assmus MA, Uçar T, Claps F, Boltri M, La Montagna G, Burnhope T, Nkwam N, Austin T, Boxall NE, Downey AP, Sukhu TA, Antón-Juanilla M, Rai S, Chin YF, Moore M, Drake T, Green JSA, Goulao B, MacLennan G, Nielsen M, McGrath JS, Kasivisvanathan V. Developing a Diagnostic Multivariable Prediction Model for Urinary Tract Cancer in Patients Referred with Haematuria: Results from the IDENTIFY Collaborative Study. Eur Urol Focus 2022; 8:1673-1682. [PMID: 35760722 DOI: 10.1016/j.euf.2022.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 03/23/2022] [Revised: 05/05/2022] [Accepted: 06/04/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation. OBJECTIVE To develop a prediction model for urinary tract cancer in patients referred with haematuria. DESIGN, SETTING, AND PARTICIPANTS A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism. RESULTS AND LIMITATIONS The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy. CONCLUSIONS This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation. PATIENT SUMMARY We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.
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Affiliation(s)
- Sinan Khadhouri
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK; Aberdeen Royal Infirmary, Aberdeen, UK; British Urology Researchers in Surgical Training (BURST) Collaborative, UK.
| | - Kevin M Gallagher
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Western General Hospital, Edinburgh, UK; Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Kenneth R MacKenzie
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Freeman Hospital, Newcastle Upon Tyne, UK
| | - Taimur T Shah
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Department of Surgery and Cancer, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Chuanyu Gao
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Addenbrookes Hospital, Cambridge, UK
| | - Sacha Moore
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Wrexham Maelor Hospital, Wrexham, UK
| | - Eleanor F Zimmermann
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Torbay and South Devon NHS Foundation Trust, Torbay, UK
| | - Eric Edison
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Department of Urology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Matthew Jefferies
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Morriston Hospital, Swansea, UK; Swansea University, Swansea, UK
| | - Arjun Nambiar
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Freeman Hospital, Newcastle Upon Tyne, UK
| | - Thineskrishna Anbarasan
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Western General Hospital, Edinburgh, UK
| | - Miles P Mannas
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | - Taeweon Lee
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | - Giancarlo Marra
- Department of Surgical Sciences, Città della Salute e della Scienza, Turin, Italy; University of Turin, Turin, Italy
| | - Juan Gómez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain
| | - Gautier Marcq
- Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France; CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, University Lille, Lille, France
| | - Mark A Assmus
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Taha Uçar
- Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Francesco Claps
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Matteo Boltri
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe La Montagna
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Tara Burnhope
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nkwam Nkwam
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Tomas Austin
- Department of Urology, Queen Alexandra Hospital, Portsmouth, UK
| | | | | | - Troy A Sukhu
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | | | - Sonpreet Rai
- St James University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | | | - Madeline Moore
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - James S A Green
- Department of Urology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK; Healthcare and Population Research, Kings College, London, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Matthew Nielsen
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - John S McGrath
- University of Exeter Medical School, Exeter, UK; Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Veeru Kasivisvanathan
- British Urology Researchers in Surgical Training (BURST) Collaborative, UK; Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
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18
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Heer R, Lewis R, Duncan A, Penegar S, Vadiveloo T, Clark E, Yu G, Mariappan P, Cresswell J, McGrath J, N'Dow J, Nabi G, Mostafid H, Kelly J, Ramsay C, Lazarowicz H, Allan A, Breckons M, Campbell K, Campbell L, Feber A, McDonald A, Norrie J, Orozco-Leal G, Rice S, Tandogdu Z, Taylor E, Wilson L, Vale L, MacLennan G, Hall E. Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT. Health Technol Assess 2022; 26:1-144. [PMID: 36300825 PMCID: PMC9639219 DOI: 10.3310/plpu1526] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Around 7500 people are diagnosed with non-muscle-invasive bladder cancer in the UK annually. Recurrence following transurethral resection of bladder tumour is common, and the intensive monitoring schedule required after initial treatment has associated costs for patients and the NHS. In photodynamic diagnosis, before transurethral resection of bladder tumour, a photosensitiser that is preferentially absorbed by tumour cells is instilled intravesically. Transurethral resection of bladder tumour is then conducted under blue light, causing the photosensitiser to fluoresce. Photodynamic diagnosis-guided transurethral resection of bladder tumour offers better diagnostic accuracy than standard white-light-guided transurethral resection of bladder tumour, potentially reducing the chance of subsequent recurrence. OBJECTIVE The objective was to assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis-guided transurethral resection of bladder tumour. DESIGN This was a multicentre, pragmatic, open-label, parallel-group, non-masked, superiority randomised controlled trial. Allocation was by remote web-based service, using a 1 : 1 ratio and a minimisation algorithm balanced by centre and sex. SETTING The setting was 22 NHS hospitals. PARTICIPANTS Patients aged ≥ 16 years with a suspected first diagnosis of high-risk non-muscle-invasive bladder cancer, no contraindications to photodynamic diagnosis and written informed consent were eligible. INTERVENTIONS Photodynamic diagnosis-guided transurethral resection of bladder tumour and standard white-light cystoscopy transurethral resection of bladder tumour. MAIN OUTCOME MEASURES The primary clinical outcome measure was the time to recurrence from the date of randomisation to the date of pathologically proven first recurrence (or intercurrent bladder cancer death). The primary health economic outcome was the incremental cost per quality-adjusted life-year gained at 3 years. RESULTS We enrolled 538 participants from 22 UK hospitals between 11 November 2014 and 6 February 2018. Of these, 269 were allocated to photodynamic diagnosis and 269 were allocated to white light. A total of 112 participants were excluded from the analysis because of ineligibility (n = 5), lack of non-muscle-invasive bladder cancer diagnosis following transurethral resection of bladder tumour (n = 89) or early cystectomy (n = 18). In total, 209 photodynamic diagnosis and 217 white-light participants were included in the clinical end-point analysis population. All randomised participants were included in the cost-effectiveness analysis. Over a median follow-up period of 21 months for the photodynamic diagnosis group and 22 months for the white-light group, there were 86 recurrences (3-year recurrence-free survival rate 57.8%, 95% confidence interval 50.7% to 64.2%) in the photodynamic diagnosis group and 84 recurrences (3-year recurrence-free survival rate 61.6%, 95% confidence interval 54.7% to 67.8%) in the white-light group (hazard ratio 0.94, 95% confidence interval 0.69 to 1.28; p = 0.70). Adverse event frequency was low and similar in both groups [12 (5.7%) in the photodynamic diagnosis group vs. 12 (5.5%) in the white-light group]. At 3 years, the total cost was £12,881 for photodynamic diagnosis-guided transurethral resection of bladder tumour and £12,005 for white light. There was no evidence of differences in the use of health services or total cost at 3 years. At 3 years, the quality-adjusted life-years gain was 2.094 in the photodynamic diagnosis transurethral resection of bladder tumour group and 2.087 in the white light group. The probability that photodynamic diagnosis-guided transurethral resection of bladder tumour was cost-effective was never > 30% over the range of society's cost-effectiveness thresholds. LIMITATIONS Fewer patients than anticipated were correctly diagnosed with intermediate- to high-risk non-muscle-invasive bladder cancer before transurethral resection of bladder tumour and the ratio of intermediate- to high-risk non-muscle-invasive bladder cancer was higher than expected, reducing the number of observed recurrences and the statistical power. CONCLUSIONS Photodynamic diagnosis-guided transurethral resection of bladder tumour did not reduce recurrences, nor was it likely to be cost-effective compared with white light at 3 years. Photodynamic diagnosis-guided transurethral resection of bladder tumour is not supported in the management of primary intermediate- to high-risk non-muscle-invasive bladder cancer. FUTURE WORK Further work should include the modelling of appropriate surveillance schedules and exploring predictive and prognostic biomarkers. TRIAL REGISTRATION This trial is registered as ISRCTN84013636. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 40. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rakesh Heer
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Anne Duncan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Steven Penegar
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Emma Clark
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Ge Yu
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | | | - Joanne Cresswell
- Department of Urology, South Tees Hospitals NHS Trust, Middlesbrough, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter Hospital NHS Trust, Exeter, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Ghulam Nabi
- School of Medicine, University of Dundee, Dundee, UK
| | - Hugh Mostafid
- Department of Urology, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
| | - John Kelly
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Henry Lazarowicz
- Department of Urology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Angela Allan
- Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Matthew Breckons
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Louise Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Andy Feber
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Giovany Orozco-Leal
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Zafer Tandogdu
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Laura Wilson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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19
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Heer R, Lewis R, Vadiveloo T, Yu G, Mariappan P, Cresswell J, McGrath J, Nabi G, Mostafid H, Lazarowicz H, Kelly J, Duncan A, Penegar S, Breckons M, Wilson L, Clark E, Feber A, Orozco-Leal G, Tandogdu Z, Taylor E, N'Dow J, Norrie J, Ramsay C, Rice S, Vale L, MacLennan G, Hall E. A Randomized Trial of PHOTOdynamic Surgery in Non-Muscle-Invasive Bladder Cancer. NEJM Evid 2022; 1:EVIDoa2200092. [PMID: 38319866 DOI: 10.1056/evidoa2200092] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
PDD or WL Resection of Tumors in NMIBCIn this open-label trial, patients with intermediate- or high-risk non-muscle-invasive bladder cancer at diagnosis were randomly assigned to photodynamic diagnosis or white light-guided transurethral resection of bladder tumor. Three-year recurrence-free rates were 57.8% and 61.6% in the PDD and WL groups, respectively, with no difference in quality-adjusted life years between the treatment groups at 3 years.
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Affiliation(s)
- Rakesh Heer
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - Ge Yu
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery, Department of Urology, Western General Hospital, Edinburgh
| | | | - John McGrath
- Royal Devon and Exeter Hospital NHS Trust, Exeter, United Kingdom
| | - Ghulam Nabi
- University of Dundee, Dundee, United Kingdom
| | - Hugh Mostafid
- Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, United Kingdom
| | - Henry Lazarowicz
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - John Kelly
- University College London Hospitals NHS Foundation Trust, London
| | - Anne Duncan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Matt Breckons
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Laura Wilson
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma Clark
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andy Feber
- University College London Hospitals NHS Foundation Trust, London
| | | | - Zafer Tandogdu
- University College London Hospitals NHS Foundation Trust, London
| | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Edinburgh University, Edinburgh
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Stephen Rice
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Luke Vale
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London
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20
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Abdel-fattah M, Johnson D, Constable L, Thomas R, Cotton S, Tripathee S, Cooper D, Boran S, Dimitropoulos K, Evans S, Granitsiotis P, Hashim H, Kilonzo M, Larcombe J, Little P, MacLennan S, Murchie P, Myint PK, N’Dow J, Norrie J, Omar MI, Paterson C, Scotland G, Thiruchelvam N, MacLennan G. Randomised controlled trial comparing the clinical and cost-effectiveness of various washout policies versus no washout policy in preventing catheter associated complications in adults living with long-term catheters: study protocol for the CATHETER II study. Trials 2022; 23:630. [PMID: 35927733 PMCID: PMC9351274 DOI: 10.1186/s13063-022-06577-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Various washout policies are widely used in adults living with long-term catheters (LTC). There is currently insufficient evidence on the benefits and potential harms of prophylactic LTC washout policies in the prevention of blockages and other LTC-related adverse events, such as urinary tract infections. CATHETER II tests the hypothesis that weekly prophylactic LTC washouts (normal saline or citric acid) in addition to standard LTC care reduce the incidence of catheter blockage requiring intervention compared to standard LTC care only in adults living with LTC. METHODS CATHETER II is a pragmatic three-arm open multi-centre superiority randomised controlled trial with an internal pilot, economic analysis, and embedded qualitative study. Eligible participants are adults aged ≥ 18 years, who have had a LTC in use for ≥ 28 days, have no plans to discontinue the use of the catheter, are able to undertake the catheter washouts, and complete trial documentation or have a carer able to help them. Participants are identified from general practitioner practices, secondary/tertiary care, community healthcare, care homes, and via public advertising strategies. Participants are randomised 1:1:1 to receive a weekly saline (0.9%) washout in addition to standard LTC care, a weekly citric acid (3.23%) washout in addition to standard LTC care or standard LTC care only. Participants and/or carers will receive training to administer the washouts. Patient-reported outcomes are collected at baseline and for 24 months post-randomisation. The primary clinical outcome is catheter blockage requiring intervention up to 24 months post-randomisation expressed per 1000 catheter days. Secondary outcomes include symptomatic catheter-associated urinary tract infection requiring antibiotics, catheter change, adverse events, NHS/ healthcare use, and impact on quality of life. DISCUSSION This study will guide treatment decision-making and clinical practice guidelines regarding the effectiveness of various prophylactic catheter washout policies in men and women living with LTC. This research has received ethical approval from Wales Research Ethics Committee 6 (19/WA/0015). TRIAL REGISTRATION ISRCTN ISRCTN17116445 . Registered prospectively on 06 November 2019.
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Affiliation(s)
- Mohamed Abdel-fattah
- grid.7107.10000 0004 1936 7291Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, UK
| | - Diana Johnson
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lynda Constable
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Ruth Thomas
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Sheela Tripathee
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sue Boran
- The Queen’s Nursing Institute, London, UK
| | | | | | | | - Hashim Hashim
- grid.418484.50000 0004 0380 7221North Bristol NHS Trust, Bristol, UK
| | - Mary Kilonzo
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Paul Little
- grid.5491.90000 0004 1936 9297Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Sara MacLennan
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- grid.7107.10000 0004 1936 7291Academic Primary Care Research Group, University of Aberdeen, Aberdeen, UK
| | - Phyo Kyaw Myint
- grid.7107.10000 0004 1936 7291Ageing Clinical & Experimental Research Team, University of Aberdeen, Aberdeen, UK
| | - James N’Dow
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- grid.4305.20000 0004 1936 7988Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Muhammad Imran Omar
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Catherine Paterson
- grid.1039.b0000 0004 0385 7472School of Nursing, Midwifery and Public Health, University of Canberra, Canberra, Australia
| | - Graham Scotland
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nikesh Thiruchelvam
- grid.24029.3d0000 0004 0383 8386Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graeme MacLennan
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
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21
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Constable L, Abrams P, Cooper D, Kilonzo M, Cotterill N, Harding C, Drake MJ, Pardoe MN, McDonald A, Smith R, Norrie J, McCormack K, Ramsay C, Uren A, Mundy T, Glazener C, MacLennan G. Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT. Health Technol Assess 2022; 26:1-152. [PMID: 35972773 PMCID: PMC9421661 DOI: 10.3310/tbfz0277] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stress urinary incontinence is common in men after prostate surgery and can be difficult to improve. Implantation of an artificial urinary sphincter is the most common surgical procedure for persistent stress urinary incontinence, but it requires specialist surgical skills, and revisions may be necessary. In addition, the sphincter is relatively expensive and its operation requires adequate patient dexterity. New surgical approaches include the male synthetic sling, which is emerging as a possible alternative. However, robust comparable data, derived from randomised controlled trials, on the relative safety and efficacy of the male synthetic sling and the artificial urinary sphincter are lacking. OBJECTIVE We aimed to compare the clinical effectiveness and cost-effectiveness of the male synthetic sling with those of the artificial urinary sphincter surgery in men with persistent stress urinary incontinence after prostate surgery. DESIGN This was a multicentre, non-inferiority randomised controlled trial, with a parallel non-randomised cohort and embedded qualitative component. Randomised controlled trial allocation was carried out by remote web-based randomisation (1 : 1), minimised on previous prostate surgery (radical prostatectomy or transurethral resection of the prostate), radiotherapy (or not, in relation to prostate surgery) and centre. Surgeons and participants were not blind to the treatment received. Non-randomised cohort allocation was participant and/or surgeon preference. SETTING The trial was set in 28 UK urological centres in the NHS. PARTICIPANTS Participants were men with urodynamic stress incontinence after prostate surgery for whom surgery was deemed appropriate. Exclusion criteria included previous sling or artificial urinary sphincter surgery, unresolved bladder neck contracture or urethral stricture after prostate surgery, and an inability to give informed consent or complete trial documentation. INTERVENTIONS We compared male synthetic sling with artificial urinary sphincter. MAIN OUTCOME MEASURES The clinical primary outcome measure was men's reports of continence (assessed from questions 3 and 4 of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) at 12 months post randomisation (with a non-inferiority margin of 15%). The primary economic outcome was cost-effectiveness (assessed as the incremental cost per quality-adjusted life-year at 24 months post randomisation). RESULTS In total, 380 men were included in the randomised controlled trial (n = 190 in each group), and 99 out of 100 men were included in the non-randomised cohort. In terms of continence, the male sling was non-inferior to the artificial urinary sphincter (intention-to-treat estimated absolute risk difference -0.034, 95% confidence interval -0.117 to 0.048; non-inferiority p = 0.003), indicating a lower success rate in those randomised to receive a sling, but with a confidence interval excluding the non-inferiority margin of -15%. In both groups, treatment resulted in a reduction in incontinence symptoms (as measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form). Between baseline and 12 months' follow-up, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score fell from 16.1 to 8.7 in the male sling group and from 16.4 to 7.5 in the artificial urinary sphincter group (mean difference for the time point at 12 months 1.30, 95% confidence interval 0.11 to 2.49; p = 0.032). The number of serious adverse events was small (male sling group, n = 8; artificial urinary sphincter group, n = 15; one man in the artificial urinary sphincter group experienced three serious adverse events). Quality-of-life scores improved and satisfaction was high in both groups. Secondary outcomes that showed statistically significant differences favoured the artificial urinary sphincter over the male sling. Outcomes of the non-randomised cohort were similar. The male sling cost less than the artificial sphincter but was associated with a smaller quality-adjusted life-year gain. The incremental cost-effectiveness ratio for male slings compared with an artificial urinary sphincter suggests that there is a cost saving of £425,870 for each quality-adjusted life-year lost. The probability that slings would be cost-effective at a £30,000 willingness-to-pay threshold for a quality-adjusted life-year was 99%. LIMITATIONS Follow-up beyond 24 months is not available. More specific surgical/device-related pain outcomes were not included. CONCLUSIONS Continence rates improved from baseline, with the male sling non-inferior to the artificial urinary sphincter. Symptoms and quality of life significantly improved in both groups. Men were generally satisfied with both procedures. Overall, secondary and post hoc analyses favoured the artificial urinary sphincter over the male sling. FUTURE WORK Participant reports of any further surgery, satisfaction and quality of life at 5-year follow-up will inform longer-term outcomes. Administration of an additional pain questionnaire would provide further information on pain levels after both surgeries. TRIAL REGISTRATION This trial is registered as ISRCTN49212975. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lynda Constable
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Nikki Cotterill
- Faculty of Health and Applied Sciences (HAS), University of the West of England, Bristol, UK
| | - Chris Harding
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marcus J Drake
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - Megan N Pardoe
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Alison McDonald
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Smith
- Research and Innovation, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - John Norrie
- Usher Institute, Centre of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alan Uren
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Tony Mundy
- Urology, University College Hospital, London, UK
| | - Cathryn Glazener
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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22
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Macaulay L, O'Dolan C, Avenell A, Carroll P, Cotton S, Dombrowski S, Elders A, Goulao B, Gray C, Harris FM, Hunt K, Kee F, MacLennan G, McDonald MD, McKinley M, Skinner R, Torrens C, Tod M, Turner K, van der Pol M, Hoddinott P. Effectiveness and cost-effectiveness of text messages with or without endowment incentives for weight management in men with obesity (Game of Stones): study protocol for a randomised controlled trial. Trials 2022; 23:582. [PMID: 35869503 PMCID: PMC9306253 DOI: 10.1186/s13063-022-06504-5] [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] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obesity increases the risk of type 2 diabetes, heart disease, stroke, mobility problems and some cancers, and its prevalence is rising. Men engage less than women in existing weight loss interventions. Game of Stones builds on a successful feasibility study and aims to find out if automated text messages with or without endowment incentives are effective and cost-effective for weight loss at 12 months compared to a waiting list comparator arm in men with obesity. METHODS A 3-arm, parallel group, assessor-blind superiority randomised controlled trial with process evaluation will recruit 585 adult men with body mass index of 30 kg/m2 or more living in and around three UK centres (Belfast, Bristol, Glasgow), purposively targeting disadvantaged areas. Intervention groups: (i) automated, theory-informed text messages daily for 12 months plus endowment incentives linked to verified weight loss targets at 3, 6 and 12 months; (ii) the same text messages and weight loss assessment protocol; (iii) comparator group: 12 month waiting list, then text messages for 3 months. The primary outcome is percentage weight change at 12 months from baseline. Secondary outcomes at 12 months are as follows: quality of life, wellbeing, mental health, weight stigma, behaviours, satisfaction and confidence. Follow-up includes weight at 24 months. A health economic evaluation will measure cost-effectiveness over the trial and over modelled lifetime: including health service resource-use and quality-adjusted life years. The cost-utility analysis will report incremental cost per quality-adjusted life years gained. Participant and service provider perspectives will be explored via telephone interviews, and exploratory mixed methods process evaluation analyses will focus on mental health, multiple long-term conditions, health inequalities and implementation strategies. DISCUSSION The trial will report whether text messages (with and without cash incentives) can help men to lose weight over 1 year and maintain this for another year compared to a comparator group; the costs and benefits to the health service; and men's experiences of the interventions. Process analyses with public involvement and service commissioner input will ensure that this open-source digital self-care intervention could be sustainable and scalable by a range of NHS or public services. TRIAL REGISTRATION ISRCTN 91974895 . Registered on 14/04/2021.
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Affiliation(s)
- Lisa Macaulay
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK.
| | - Catriona O'Dolan
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK
| | - Alison Avenell
- Health Services Research Unit, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Paula Carroll
- Department Sport & Exercise Science, Waterford Institute of Technology, Main Campus Cork RoadCo. Waterford, Waterford City, Ireland
| | - Seonaidh Cotton
- CHaRT, HRSU, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Stephan Dombrowski
- Faculty of Kinesiology, University of New Brunswick, 3 Bailey Drive, P.O. Box 4400, Fredericton, NB, E3B 5A3, Canada
| | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, G4 0BA, Glasgow, UK
| | - Beatriz Goulao
- CHaRT, HRSU, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Cindy Gray
- School of Social and Political Sciences, University of Glasgow, 25-29 Bute Gardens, Glasgow, G12 8RS, UK
| | - Fiona M Harris
- School of Health & Life Sciences, University of the West of Scotland, High Street, Paisley, Renfrewshire, PA1 2BE, UK
| | - Kate Hunt
- Institute for Social Marketing and Health, Pathfoot Building, University of Stirling, Stirling, FK9 4LA, UK
| | - Frank Kee
- Centre for Public Health, UKCRC Centre of Excellence for Public Health Research (NI), Institute Clinical Sciences A, Grosvenor Road, Belfast, BT12 6BJ, Northern Ireland
| | - Graeme MacLennan
- CHaRT, HRSU, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | | | - Michelle McKinley
- Queen's University Belfast, University Road, Belfast, BT7 1NN, Northern Ireland
| | | | - Claire Torrens
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK
| | - Martin Tod
- Men's Health Forum, 49-51 East Rd, Hoxton, London, N1 6AH, UK
| | - Katrina Turner
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Marjon van der Pol
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Pat Hoddinott
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK
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23
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Gumley AI, Bradstreet S, Ainsworth J, Allan S, Alvarez-Jimenez M, Birchwood M, Briggs A, Bucci S, Cotton S, Engel L, French P, Lederman R, Lewis S, Machin M, MacLennan G, McLeod H, McMeekin N, Mihalopoulos C, Morton E, Norrie J, Reilly F, Schwannauer M, Singh SP, Sundram S, Thompson A, Williams C, Yung A, Aucott L, Farhall J, Gleeson J. Digital smartphone intervention to recognise and manage early warning signs in schizophrenia to prevent relapse: the EMPOWER feasibility cluster RCT. Health Technol Assess 2022; 26:1-174. [PMID: 35639493 DOI: 10.3310/hlze0479] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Relapse is a major determinant of outcome for people with a diagnosis of schizophrenia. Early warning signs frequently precede relapse. A recent Cochrane Review found low-quality evidence to suggest a positive effect of early warning signs interventions on hospitalisation and relapse. OBJECTIVE How feasible is a study to investigate the clinical effectiveness and cost-effectiveness of a digital intervention to recognise and promptly manage early warning signs of relapse in schizophrenia with the aim of preventing relapse? DESIGN A multicentre, two-arm, parallel-group cluster randomised controlled trial involving eight community mental health services, with 12-month follow-up. SETTINGS Glasgow, UK, and Melbourne, Australia. PARTICIPANTS Service users were aged > 16 years and had a schizophrenia spectrum disorder with evidence of a relapse within the previous 2 years. Carers were eligible for inclusion if they were nominated by an eligible service user. INTERVENTIONS The Early signs Monitoring to Prevent relapse in psychosis and prOmote Wellbeing, Engagement, and Recovery (EMPOWER) intervention was designed to enable participants to monitor changes in their well-being daily using a mobile phone, blended with peer support. Clinical triage of changes in well-being that were suggestive of early signs of relapse was enabled through an algorithm that triggered a check-in prompt that informed a relapse prevention pathway, if warranted. MAIN OUTCOME MEASURES The main outcomes were feasibility of the trial and feasibility, acceptability and usability of the intervention, as well as safety and performance. Candidate co-primary outcomes were relapse and fear of relapse. RESULTS We recruited 86 service users, of whom 73 were randomised (42 to EMPOWER and 31 to treatment as usual). Primary outcome data were collected for 84% of participants at 12 months. Feasibility data for people using the smartphone application (app) suggested that the app was easy to use and had a positive impact on motivations and intentions in relation to mental health. Actual app usage was high, with 91% of users who completed the baseline period meeting our a priori criterion of acceptable engagement (> 33%). The median time to discontinuation of > 33% app usage was 32 weeks (95% confidence interval 14 weeks to ∞). There were 8 out of 33 (24%) relapses in the EMPOWER arm and 13 out of 28 (46%) in the treatment-as-usual arm. Fewer participants in the EMPOWER arm had a relapse (relative risk 0.50, 95% confidence interval 0.26 to 0.98), and time to first relapse (hazard ratio 0.32, 95% confidence interval 0.14 to 0.74) was longer in the EMPOWER arm than in the treatment-as-usual group. At 12 months, EMPOWER participants were less fearful of having a relapse than those in the treatment-as-usual arm (mean difference -4.29, 95% confidence interval -7.29 to -1.28). EMPOWER was more costly and more effective, resulting in an incremental cost-effectiveness ratio of £3041. This incremental cost-effectiveness ratio would be considered cost-effective when using the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained. LIMITATIONS This was a feasibility study and the outcomes detected cannot be taken as evidence of efficacy or effectiveness. CONCLUSIONS A trial of digital technology to monitor early warning signs that blended with peer support and clinical triage to detect and prevent relapse is feasible. FUTURE WORK A main trial with a sample size of 500 (assuming 90% power and 20% dropout) would detect a clinically meaningful reduction in relapse (relative risk 0.7) and improvement in other variables (effect sizes 0.3-0.4). TRIAL REGISTRATION This trial is registered as ISRCTN99559262. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 27. See the NIHR Journals Library website for further project information. Funding in Australia was provided by the National Health and Medical Research Council (APP1095879).
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Affiliation(s)
- Andrew I Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Simon Bradstreet
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John Ainsworth
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stephanie Allan
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Maximillian Birchwood
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sue Cotton
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Lidia Engel
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Paul French
- Department of Nursing, Manchester Metropolitan University, Manchester, UK
| | - Reeva Lederman
- School of Computing and Information Systems, Melbourne School of Engineering, University of Melbourne, Melbourne, VIC, Australia
| | - Shôn Lewis
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Hamish McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cathy Mihalopoulos
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Emma Morton
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Swaran P Singh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Suresh Sundram
- Department of Psychiatry, Monash University, Melbourne, VIC, Australia
| | - Andrew Thompson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris Williams
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alison Yung
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Farhall
- Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia.,NorthWestern Mental Health, Melbourne, VIC, Australia
| | - John Gleeson
- Healthy Brain and Mind Research Centre, Australian Catholic University, Melbourne, VIC, Australia
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24
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Gumley AI, Bradstreet S, Ainsworth J, Allan S, Alvarez-Jimenez M, Aucott L, Birchwood M, Briggs A, Bucci S, Cotton SM, Engel L, French P, Lederman R, Lewis S, Machin M, MacLennan G, McLeod H, McMeekin N, Mihalopoulos C, Morton E, Norrie J, Schwannauer M, Singh SP, Sundram S, Thompson A, Williams C, Yung AR, Farhall J, Gleeson J. The EMPOWER blended digital intervention for relapse prevention in schizophrenia: a feasibility cluster randomised controlled trial in Scotland and Australia. Lancet Psychiatry 2022; 9:477-486. [PMID: 35569503 DOI: 10.1016/s2215-0366(22)00103-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Received: 11/04/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early warning signs monitoring by service users with schizophrenia has shown promise in preventing relapse but the quality of evidence is low. We aimed to establish the feasibility of undertaking a definitive randomised controlled trial to determine the effectiveness of a blended digital intervention for relapse prevention in schizophrenia. METHODS This multicentre, feasibility, cluster randomised controlled trial aimed to compare Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) with treatment as usual in community mental health services (CMHS) in Glasgow and Melbourne. CMHS were the unit of randomisation, selected on the basis of those that probably had five or more care coordinators willing to participate. Participants were eligible if they were older than 16 years, had a schizophrenia or related diagnosis confirmed via case records, were able to provide informed consent, had contact with CMHS, and had had a relapse within the previous 2 years. Participants were randomised within stratified clusters to EMPOWER or to continue their usual approach to care. EMPOWER blended a smartphone for active monitoring of early warning signs with peer support to promote self-management and clinical triage to promote access to relapse prevention. Main outcomes were feasibility, acceptability, usability, and safety, which was assessed through face-to-face interviews. App usage was assessed via the smartphone and self-report. Primary end point was 12 months. Participants, research assistants and other team members involved in delivering the intervention were not masked to treatment conditions. Assessment of relapse was done by an independent adjudication panel masked to randomisation group. The study is registered at ISRCTN (99559262). FINDINGS We identified and randomised eight CMHS (six in Glasgow and two in Melbourne) comprising 47 care coordinators. We recruited 86 service users between Jan 19 and Aug 8, 2018; 73 were randomised (42 [58%] to EMPOWER and 31 [42%] to treatment as usual). There were 37 (51%) men and 36 (49%) women. At 12 months, main outcomes were collected for 32 (76%) of service users in the EMPOWER group and 30 (97%) of service users in the treatment as usual group. Of those randomised to EMPOWER, 30 (71%) met our a priori criterion of more than 33% adherence to daily monitoring that assumed feasibility. Median time to discontinuation of these participants was 31·5 weeks (SD 14·5). There were 29 adverse events in the EMPOWER group and 25 adverse events in the treatment as usual group. There were 13 app-related adverse events, affecting 11 people, one of which was serious. Fear of relapse was lower in the EMPOWER group than in the treatment as usual group at 12 months (mean difference -7·53 (95% CI -14·45 to 0·60; Cohen's d -0·53). INTERPRETATION A trial of digital technology to monitor early warning signs blended with peer support and clinical triage to detect and prevent relapse appears to be feasible, safe, and acceptable. A further main trial is merited. FUNDING UK National Institute for Health Research Health Technology Assessment programme and the Australian National Health and Medical Research Council.
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Affiliation(s)
- Andrew I Gumley
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Simon Bradstreet
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John Ainsworth
- Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Stephanie Allan
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mario Alvarez-Jimenez
- Orygen Melbourne, Melbourne, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Lorna Aucott
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Maximillian Birchwood
- Centre for Mental Health and Wellbeing Research, Warwick Medical School, University of Warwick, Warwick, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sue M Cotton
- Orygen Melbourne, Melbourne, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Lidia Engel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul French
- Department of Psychiatry, Manchester Metropolitan University, Manchester, UK
| | - Reeva Lederman
- School of Computing and Information Systems, Faculty of Engineering and Information Technology, University of Melbourne, Melbourne, VIC, Australia
| | - Shôn Lewis
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Machin
- Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Hamish McLeod
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cathy Mihalopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Emma Morton
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - John Norrie
- The Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Swaran P Singh
- Centre for Mental Health and Wellbeing Research, Warwick Medical School, University of Warwick, Warwick, UK
| | - Suresh Sundram
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Mental Health Program, Monash Health, Melbourne, VIC, Australia
| | - Andrew Thompson
- Orygen Melbourne, Melbourne, VIC, Australia; Centre for Mental Health and Wellbeing Research, Warwick Medical School, University of Warwick, Warwick, UK
| | - Chris Williams
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alison R Yung
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; School of Medicine, Deakin University, Melbourne, VIC, Australia
| | - John Farhall
- Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia; NorthWestern Mental Health, The Royal Melbourne Hospital, Epping, VIC, Australia
| | - John Gleeson
- Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
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Turner S, Cotton S, Wood J, Bell V, Raja EA, Scott NW, Morgan H, Lawrie L, Emele D, Kennedy C, Scotland G, Fielding S, MacLennan G, Norrie J, Forrest M, Gaillard EA, de Jongste J, Pijnenburg M, Thomas M, Price D. Reducing asthma attacks in children using exhaled nitric oxide (RAACENO) as a biomarker to inform treatment strategy: a multicentre, parallel, randomised, controlled, phase 3 trial. Lancet Respir Med 2022; 10:584-592. [PMID: 35101183 DOI: 10.1016/s2213-2600(21)00486-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The benefit of fractional exhaled nitric oxide (FeNO) in guiding asthma treatment is uncertain. We evaluated the efficacy of adding FeNO to symptom-guided treatment in children with asthma versus only symptom-guided treatment. METHODS RAACENO was a multicentre, parallel, randomised, controlled, phase 3 trial done in 35 secondary care centres and 17 primary care recruitment sites (only seven primary care sites managed to recruit patients) in the UK. Patients with a confirmed asthma diagnosis, aged 6-15 years, prescribed inhaled corticosteroids, and who received a course of oral corticosteroids for at least one asthma exacerbation during the 12 months before recruitment were included. Participants were randomly assigned to either FeNO plus symptom-guided treatment (intervention) or symptom-guided treatment alone (standard care) using a 24 h in-house, web-based randomisation system. Participants and the clinical and research teams were not masked to the group allocation. A web-based algorithm gave treatment recommendations based on the Asthma Control Test (ACT) or Childhood ACT (CACT) score; current asthma treatment; adherence to study treatment in the past 3 months; and use of FeNO (in the intervention group). Follow-up occurred at 3-month intervals for 12 months. The primary outcome was any asthma exacerbation treated with oral corticosteroids in the 12 months after randomisation, assessed in the intention-to-treat population. This study is registered with the International Standard Randomised Controlled Trial Registry, ISRCTN67875351. FINDINGS Between June 22, 2017, and Aug 8, 2019, 535 children were assessed for eligibility, 20 were ineligible and six were excluded post-randomisation. 509 children were recruited and at baseline, the mean age of participants was 10·1 years (SD 2·6), and 308 (60·5%) were male. The median FeNO was 21 ppb (IQR 10-48), mean predicted FEV1 was 89·6% (SD 18·0), and median daily dose of inhaled corticosteroids was 400 μg budesonide equivalent (IQR 400-1000). Asthma was partly or fully controlled in 256 (50·3%) of 509 participants. The primary outcome, which was available for 506 (99%) of 509 participants, occurred in 123 (48·2%) of 255 participants in the intervention group and 129 (51·4%) of 251 in the standard care group, the intention-to-treat adjusted odds ratio (OR) was 0·88 (95% CI 0·61 to 1·27; p=0·49). The adjusted difference in the percentage of participants who received the intervention in whom the primary outcome occurred compared with those who received standard care was -3·1% (-11·9% to 5·6%). In 377 (21·3%) of 1771 assessments, the algorithm recommendation was not followed. Adverse events were reported by 27 (5·3%) of 509 participants (15 in the standard care group and 12 in the intervention group). The most common adverse event was itch after skin prick testing (reported by eight participants in each group). INTERPRETATION We found that the addition of FeNO to symptom-guided asthma treatment did not lead to reduced exacerbations among children prone to asthma exacerbation. Asthma symptoms remain the only tool for guiding treatment decisions. FUNDING National Institute for Health Research.
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Affiliation(s)
- Steve Turner
- Royal Aberdeen Children's Hospital, University of Aberdeen, Aberdeen, UK.
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jessica Wood
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Bell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Neil W Scott
- Department of Medical Statistics, University of Aberdeen, Aberdeen, UK
| | - Heather Morgan
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Emele
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Shona Fielding
- Department of Medical Statistics, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Erol A Gaillard
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | | | - Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - David Price
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Observational and Pragmatic Research Institute, Singapore
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26
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Phillips R, Cro S, Wheeler G, Bond S, Morris TP, Creanor S, Hewitt C, Love S, Lopes A, Schlackow I, Gamble C, MacLennan G, Habron C, Gordon AC, Vergis N, Li T, Qureshi R, Everett CC, Holmes J, Kirkham A, Peckitt C, Pirrie S, Ahmed N, Collett L, Cornelius V. Visualising harms in publications of randomised controlled trials: consensus and recommendations. BMJ 2022; 377:e068983. [PMID: 35577357 PMCID: PMC9108928 DOI: 10.1136/bmj-2021-068983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To improve communication of harm in publications of randomised controlled trials via the development of recommendations for visually presenting harm outcomes. DESIGN Consensus study. SETTING 15 clinical trials units registered with the UK Clinical Research Collaboration, an academic population health department, Roche Products, and The BMJ. PARTICIPANTS Experts in clinical trials: 20 academic statisticians, one industry statistician, one academic health economist, one data graphics designer, and two clinicians. MAIN OUTCOME measures A methodological review of statistical methods identified visualisations along with those recommended by consensus group members. Consensus on visual recommendations was achieved (at least 60% of the available votes) over a series of three meetings with participants. The participants reviewed and critically appraised candidate visualisations against an agreed framework and voted on whether to endorse each visualisation. Scores marginally below this threshold (50-60%) were revisited for further discussions and votes retaken until consensus was reached. RESULTS 28 visualisations were considered, of which 10 are recommended for researchers to consider in publications of main research findings. The choice of visualisations to present will depend on outcome type (eg, binary, count, time-to-event, or continuous), and the scenario (eg, summarising multiple emerging events or one event of interest). A decision tree is presented to assist trialists in deciding which visualisations to use. Examples are provided of each endorsed visualisation, along with an example interpretation, potential limitations, and signposting to code for implementation across a range of standard statistical software. Clinician feedback was incorporated into the explanatory information provided in the recommendations to aid understanding and interpretation. CONCLUSIONS Visualisations provide a powerful tool to communicate harms in clinical trials, offering an alternative perspective to the traditional frequency tables. Increasing the use of visualisations for harm outcomes in clinical trial manuscripts and reports will provide clearer presentation of information and enable more informative interpretations. The limitations of each visualisation are discussed and examples of where their use would be inappropriate are given. Although the decision tree aids the choice of visualisation, the statistician and clinical trial team must ultimately decide the most appropriate visualisations for their data and objectives. Trialists should continue to examine crude numbers alongside visualisations to fully understand harm profiles.
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Affiliation(s)
- Rachel Phillips
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
- Pragmatic Clinical Trials Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim P Morris
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Siobhan Creanor
- Exeter Clinical Trials Unit, University of Exeter, Exeter, UK
| | | | - Sharon Love
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Andre Lopes
- CRUK Cancer Trials Centre, University College London, London, UK
| | - Iryna Schlackow
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Graeme MacLennan
- Centre for Health Care Randomised Trials, University of Aberdeen, Aberdeen, UK
| | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Nikhil Vergis
- Imperial College London and Imperial NHS Trust, London, UK
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Riaz Qureshi
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Holmes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Clare Peckitt
- Royal Marsden Clinical Trials Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Pirrie
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Norin Ahmed
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Laura Collett
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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Jansen JO, Cochran C, Boyers D, Gillies K, Lendrum R, Sadek S, Lecky F, MacLennan G, Campbell MK. The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial). Trials 2022; 23:384. [PMID: 35550642 PMCID: PMC9097076 DOI: 10.1186/s13063-022-06346-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. METHODS Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. DISCUSSION This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. TRIAL REGISTRATION ISRCTN16184981.
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Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
- Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, 35294, USA.
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Sam Sadek
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Bennett SE, Almeida C, Bachmair EM, Gray SR, Lovell K, Paul L, Wearden A, Macfarlane GJ, Basu N, Dures E, Aucott L, Martin K, Dhaun N, Emsley R, Kidd E, Kumar V, MacLennan G, Paul M, Norrie J, Packham J, Ralston SH, Siebert S, Nicol A, Norris K, Mann S, Van Lierop L, Gomez E, McCurdy F, Findlay V, Hastie N, Morgan E, Emmanuel R, Whibley D, Urquart A, MacPerson L, Rowland J, Kiddie G, Pankhurst D, Paul J, Nicholson H, Dunsmore A, Knight A, Ellis J, Maclean C, Crighton L, Shearer C, Coyle J, Begg S, Ackerman L, Carnevale J, Arbuthnot S, Watters H, Dockrell D, Hamilton D, Salutous D, Cathcart S, Rimmer D, Hughes E, Harvey J, Gillies M, Webster S, Milne L, Semple G, Duffy K, Turner L, Alexander J, Innes J, Clark C, Meek C, McKenna E, Routledge C, Hinchcliffe-Hume H, Traianos E, Dibnah B, Storey D, O'Callaghan G, Baron JY, Hunt S, Wheat N, Smith P, Barcroft EA, Thompson A, Tomlinson J, Barber J, MacPerson G, White P, Hewlett S. Remotely delivered cognitive-behavioural and personalized exercise interventions to lessen the impact of fatigue: a qualitative evaluation. Rheumatol Adv Pract 2022; 6:rkac051. [PMID: 35795008 PMCID: PMC9252174 DOI: 10.1093/rap/rkac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/08/2022] [Accepted: 06/13/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Fatigue can be a disabling symptom of inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) is a randomized trial of remotely delivered cognitive-behavioural approach or personalized exercise programme interventions, compared with usual care. The aim of this nested qualitative study was to evaluate participants’ experiences of taking part in the intervention, including their ideas about future service delivery.
Methods
Semi-structured telephone interviews were conducted with a subgroup of LIFT participants to discuss their views and experiences of the interventions.
Results
Forty-three participants (30 women) from six sites who had participated in the cognitive-behavioural approach (n = 22) or personalized exercise programme (n = 21) interventions took part. Five themes were identified in the thematic analysis. In the theme ‘not a miracle cure, but a way to better manage fatigue’, LIFT could not cure fatigue; however, most felt better able to manage after participating. Participants valued ‘building a therapeutic relationship’ with the same therapist throughout the intervention. In ‘structure, self-monitoring and being accountable’, participants liked the inclusion of goal-setting techniques and were motivated by reporting back to the therapist.
After taking part in the interventions, participants felt ‘better equipped to cope with fatigue’; more confident and empowered. Lastly, participants shared ideas for ‘a tailored programme delivered remotely’, including follow-up sessions, video calling, and group-based sessions for social support.
Conclusion
Many participants engaged with the LIFT interventions and reported benefits of taking part. This suggests an important future role for the remote delivery of fatigue self-management.
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Affiliation(s)
- Sarah E Bennett
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol
| | - Celia Almeida
- School of Health and Social Wellbeing, University of the West of England
- Academic Rheumatology, Bristol Royal Infirmary , Bristol
| | - Eva-Maria Bachmair
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen , Aberdeen
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester , Manchester
| | - Lorna Paul
- School of Health and Life Science, Glasgow Caledonian University , Glasgow
| | - Alison Wearden
- Division of Psychology and Mental Health, University of Manchester , Manchester
| | - Gary J Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen , Aberdeen
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow , Glasgow, UK
| | - Emma Dures
- School of Health and Social Wellbeing, University of the West of England
- Academic Rheumatology, Bristol Royal Infirmary , Bristol
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29
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Cotton S, Devereux G, Abbas H, Briggs A, Campbell K, Chaudhuri R, Choudhury G, Dawson D, De Soyza A, Fielding S, Gompertz S, Haughney J, Lang CC, Lee AJ, MacLennan G, MacNee W, McCormack K, McMeekin N, Mills NL, Morice A, Norrie J, Petrie MC, Price D, Short P, Vestbo J, Walker P, Wedzicha J, Wilson A, Lipworth BJ. Use of the oral beta blocker bisoprolol to reduce the rate of exacerbation in people with chronic obstructive pulmonary disease (COPD): a randomised controlled trial (BICS). Trials 2022; 23:307. [PMID: 35422024 PMCID: PMC9009490 DOI: 10.1186/s13063-022-06226-8] [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] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/26/2022] [Indexed: 12/13/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity, mortality and healthcare costs. Beta blockers are well-established drugs widely used to treat cardiovascular conditions. Observational studies consistently report that beta blocker use in people with COPD is associated with a reduced risk of COPD exacerbations. The bisoprolol in COPD study (BICS) investigates whether adding bisoprolol to routine COPD treatment has clinical and cost-effective benefits. A sub-study will risk stratify participants for heart failure to investigate whether any beneficial effect of bisoprolol is restricted to those with unrecognised heart disease. Methods BICS is a pragmatic randomised parallel group double-blind placebo-controlled trial conducted in UK primary and secondary care sites. The major inclusion criteria are an established predominant respiratory diagnosis of COPD (post-bronchodilator FEV1 < 80% predicted, FEV1/FVC < 0.7), a self-reported history of ≥ 2 exacerbations requiring treatment with antibiotics and/or oral corticosteroids in a 12-month period since March 2019, age ≥ 40 years and a smoking history ≥ 10 pack years. A computerised randomisation system will allocate 1574 participants with equal probability to intervention or control groups, stratified by centre and recruitment in primary/secondary care. The intervention is bisoprolol (1.25 mg tablets) or identical placebo. The dose of bisoprolol/placebo is titrated up to a maximum of 4 tablets a day (5 mg bisoprolol) over 4–7 weeks depending on tolerance to up-dosing of bisoprolol/placebo—these titration assessments are completed by telephone or video call. Participants complete the remainder of the 52-week treatment period on the final titrated dose (1, 2, 3, 4 tablets) and during that time are followed up at 26 and 52 weeks by telephone or video call. The primary outcome is the total number of participant reported COPD exacerbations requiring oral corticosteroids and/or antibiotics during the 52-week treatment period. A sub-study will risk stratify participants for heart failure by echocardiography and measurement of blood biomarkers. Discussion The demonstration that bisoprolol reduces the incidence of exacerbations would be relevant not only to patients and clinicians but also to healthcare providers, in the UK and globally. Trial registration Current controlled trials ISRCTN10497306. Registered on 16 August 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06226-8.
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Affiliation(s)
- Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Graham Devereux
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK. .,Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Hassan Abbas
- Division of Applied Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Andrew Briggs
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Rekha Chaudhuri
- Gartnavel General Hospital, University of Glasgow, Glasgow, G12 0YN, UK
| | | | - Dana Dawson
- Division of Applied Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Anthony De Soyza
- University of Newcastle, Medical School, Newcastle Upon Tyne, NE2 4HH, UK
| | - Shona Fielding
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Simon Gompertz
- Queen Elizabeth Hospital Birmingham, Birmingham, B15 2WB, UK
| | - John Haughney
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Chim C Lang
- Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| | - Amanda J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - William MacNee
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Nicola McMeekin
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Alyn Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull, HU16 5JQ, UK
| | - John Norrie
- NINE Edinburgh BioQuarter, University of Edinburgh, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Mark C Petrie
- Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TD, UK
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | | | - Jorgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, M23 9LT, UK
| | - Paul Walker
- Liverpool University Hospitals Foundation NHS Trust, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, UK
| | - Jadwiga Wedzicha
- National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK
| | - Andrew Wilson
- Department of Medicine, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Brian J Lipworth
- Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
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30
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Newlands R, Duncan E, Treweek S, Elliott J, Presseau J, Bower P, MacLennan G, Ogden M, Wells M, Witham MD, Young B, Gillies K. The development of theory-informed participant-centred interventions to maximise participant retention in randomised controlled trials. Trials 2022; 23:268. [PMID: 35395930 PMCID: PMC8994320 DOI: 10.1186/s13063-022-06218-8] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background A failure of clinical trials to retain participants can influence the trial findings and significantly impact the potential of the trial to influence clinical practice. Retention of participants involves people, often the trial participants themselves, performing a behaviour (e.g. returning a questionnaire or attending a follow-up clinic as part of the research). Most existing interventions that aim to improve the retention of trial participants fail to describe any theoretical basis for the potential effect (on behaviour) and also whether there was any patient and/or participant input during development. The aim of this study was to address these two problems by developing theory- informed, participant-centred, interventions to improve trial retention. Methods This study was informed by the Theoretical Domains Framework and Behaviour Change Techniques Taxonomy to match participant reported determinants of trial retention to theoretically informed behaviour change strategies. The prototype interventions were described and developed in a co-design workshop with trial participants. Acceptability and feasibility (guided by (by the Theoretical Framework of Acceptability) of two prioritised retention interventions was explored during a focus group involving a range of trial stakeholders (e.g. trial participants, trial managers, research nurses, trialists, research ethics committee members). Following focus group discussions stakeholders completed an intervention acceptability questionnaire. Results Eight trial participants contributed to the co-design of the retention interventions. Four behaviour change interventions were designed: (1) incentives and rewards for follow-up clinic attendance, (2) goal setting for improving questionnaire return, (3) participant self-monitoring to improve questionnaire return and/or clinic attendance, and (4) motivational information to improve questionnaire return and clinic attendance. Eighteen trial stakeholders discussed the two prioritised interventions. The motivational information intervention was deemed acceptable and considered straightforward to implement whilst the goal setting intervention was viewed as less clear and less acceptable. Conclusions This is the first study to develop interventions to improve trial retention that are based on the accounts of trial participants and also conceptualised and developed as behaviour change interventions (to encourage attendance at trial research visit or return a trial questionnaire). Further testing of these interventions is required to assess effectiveness. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06218-8.
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Affiliation(s)
- Rumana Newlands
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Eilidh Duncan
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Shaun Treweek
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | | | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,School of Psychology, University of Ottawa, Ottawa, Canada
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | | | - Mary Wells
- Faculty of Medicine, Department of Surgery and Cancer, Imperial College, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Miles D Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK.
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Clarkson JE, Ramsay CR, Mannocci F, Jarad F, Albadri S, Ricketts D, Tait C, Banerjee A, Deery C, Boyers D, Marshman Z, Goulao B, Hamilton AR, Banister K, Bell R, Brown L, Conway DI, Donaldson P, Duncan A, Dunn K, Fee P, Forrest M, Glenny AM, Gouick J, Gupta E, Jacobsen E, Kettle J, MacLennan G, Macpherson L, McGuff T, Mitchell F, van der Pol M, Moazzez R, Roberston D, Wojewodka G, Young L, Lamont T, Lamont T. Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP): a feasibility study. Pilot Feasibility Stud 2022; 8:77. [PMID: 35366952 PMCID: PMC8976106 DOI: 10.1186/s40814-022-01029-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Progression of dental caries can result in irreversible pulpal damage. Partial irreversible pulpitis is the initial stage of this damage, confined to the coronal pulp whilst the radicular pulp shows little or no sign of infection. Preserving the pulp with sustained vitality and developing minimally invasive biologically based therapies are key themes within contemporary clinical practice. However, root canal treatment involving complete removal of the pulp is often the only option (other than extraction) given to patients with irreversible pulpitis, with substantial NHS and patient incurred costs. The European Society of Endodontology's (ESE 2019) recent consensus statement recommends full pulpotomy, where the inflamed coronal pulp is removed with the goal of keeping the radicular pulp vital, as a more minimally invasive technique, potentially avoiding complex root canal treatment. Although this technique may be provided in secondary care, it has not been routinely implemented or evaluated in UK General Dental Practice. METHOD This feasibility study aims to identify and assess in a primary care setting the training needs of general dental practitioners and clinical fidelity of the full pulpotomy intervention, estimate likely eligible patient pool and develop recruitment materials ahead of the main randomised controlled trial comparing the clinical and cost-effectiveness of full pulpotomy compared to root canal treatment in pre/molar teeth of adults 16 years and older showing signs indicative of irreversible pulpitis. The feasibility study will recruit and train 10 primary care dentists in the full pulpotomy technique. Dentists will recruit and provide full pulpotomy to 40 participants (four per practice) with indications of partial irreversible pulpitis. DISCUSSION The Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP) study will address the lack of high-quality evidence in the treatment of irreversible pulpitis, to aid dental practitioners, patients and policymakers in their decision-making. The PIP feasibility study will inform the main study on the practicality of providing both training and provision of the full pulpotomy technique in general dental practice. TRIAL REGISTRATION ISRCTN Registry, ISRCTN17973604 . Registered on 28 January 2021. Protocol version Protocol version: 1; date: 03.02.2021.
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Affiliation(s)
- Jan E. Clarkson
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK ,grid.451102.30000 0001 0164 4922NHS Education for Scotland, Edinburgh, UK
| | - Craig R. Ramsay
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Francesco Mannocci
- grid.13097.3c0000 0001 2322 6764Centre for clinical and translational sciences, King’s College London, London, UK
| | - Fadi Jarad
- grid.10025.360000 0004 1936 8470School of Dentistry, University of Liverpool, Liverpool, UK
| | - Sondos Albadri
- grid.10025.360000 0004 1936 8470School of Dentistry, University of Liverpool, Liverpool, UK
| | - David Ricketts
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Carol Tait
- grid.8241.f0000 0004 0397 2876Dundee Dental School, The University of Dundee, Dundee, UK
| | - Avijit Banerjee
- grid.13097.3c0000 0001 2322 6764Faculty of Dentistry, Oral & Craniofacial Services, Kings College London, London, UK
| | - Chris Deery
- grid.11835.3e0000 0004 1936 9262School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Dwayne Boyers
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zoe Marshman
- grid.11835.3e0000 0004 1936 9262School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Beatriz Goulao
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alice R. Hamilton
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Katie Banister
- grid.7107.10000 0004 1936 7291Patient and Public Involvement Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rosanne Bell
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Lori Brown
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - David I. Conway
- grid.8756.c0000 0001 2193 314XSchool of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Pina Donaldson
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Anne Duncan
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katharine Dunn
- grid.4305.20000 0004 1936 7988Edinburgh Dental Institute, NHS Lothian, Edinburgh, UK
| | - Patrick Fee
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Mark Forrest
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Anne-Marie Glenny
- grid.5379.80000000121662407Division of Dentistry, University of Manchester, Manchester, UK
| | - Jill Gouick
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Ekta Gupta
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Elisabet Jacobsen
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jennifer Kettle
- grid.11835.3e0000 0004 1936 9262School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Graeme MacLennan
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lorna Macpherson
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Tina McGuff
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Fiona Mitchell
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Marjon van der Pol
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Moazzez
- grid.13097.3c0000 0001 2322 6764Oral Clinical Research Unit, King’s College London, London, UK
| | - Douglas Roberston
- grid.8756.c0000 0001 2193 314XSchool of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Gabriella Wojewodka
- grid.13097.3c0000 0001 2322 6764Faculty of Dentistry, Oral & Craniofacial Services, Kings College London, London, UK
| | - Linda Young
- grid.451102.30000 0001 0164 4922NHS Education for Scotland, Edinburgh, UK
| | - Thomas Lamont
- grid.8241.f0000 0004 0397 2876Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN UK
| | - Thomas Lamont
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
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MacLeod C, Hudson J, Brogan M, Cotton S, Treweek S, MacLennan G, Watson AJM. ScotCap - A large observational cohort study. Colorectal Dis 2022; 24:411-421. [PMID: 34935278 PMCID: PMC9305214 DOI: 10.1111/codi.16029] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 09/27/2021] [Revised: 11/28/2021] [Accepted: 12/14/2021] [Indexed: 12/13/2022]
Abstract
AIM The aim of this work was to evaluate the performance of colon capsule endoscopy (CCE) in a lower gastrointestinal diagnostic care pathway. METHOD This large multicentre prospective clinical evaluation recruited symptomatic patients (patients requiring investigation of symptoms suggestive of colorectal pathology) and surveillance patients (patients due to undergo surveillance colonoscopy). Patients aged 18 years or over were invited to participate and undergo CCE by a secondary-care clinician if they met the referral criteria for a colonoscopy. The primary outcome was the test completion rate (visualization of the whole colon and rectum). We also measured the need for further tests after CCE. RESULTS A total of 733 patients were invited to take part in this evaluation, with 509 patients undergoing CCE. Of these, 316 were symptomatic patients and 193 were surveillance patients. Two hundred and twenty-eight of the 316 symptomatic patients (72%) and 137 of the 193 surveillance patients (71%) had a complete test. It was found that 118/316 (37%) of symptomatic patients required no further test following CCE, while 103/316 (33%) and 81/316 (26%) required a colonoscopy and flexible sigmoidoscopy, respectively. Fifty-three of the 193 surveillance patients (28%) required no further test following CCE, while 104/193 (54%) and 30/193 (16%) required a colonoscopy and flexible sigmoidoscopy, respectively. No patient in this evaluation was diagnosed with colorectal cancer. Two patients experienced serious adverse events - one capsule retention with obstruction and one hospital admission with dehydration due to the bowel preparation. CONCLUSION CCE is a safe, well-tolerated diagnostic test which can reduce the proportion of patients requiring colonoscopy, but the test completion rate needs to be improved to match that of lower gastrointestinal endoscopy.
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Affiliation(s)
| | - Jemma Hudson
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | | | - Seonaidh Cotton
- Health Services Research UnitThe Centre for Healthcare Randomised TrialsUniversity of AberdeenAberdeenUK
| | - Shaun Treweek
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | - Graeme MacLennan
- Health Services Research UnitThe Centre for Healthcare Randomised TrialsUniversity of AberdeenAberdeenUK
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Abdel-Fattah M, Cooper D, Davidson T, Kilonzo M, Hossain M, Boyers D, Bhal K, Wardle J, N'Dow J, MacLennan G, Norrie J. Single-Incision Mini-Slings for Stress Urinary Incontinence in Women. N Engl J Med 2022; 386:1230-1243. [PMID: 35353961 DOI: 10.1056/nejmoa2111815] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Until recently, synthetic midurethral slings (made of mesh or tape) were the standard surgical treatment worldwide for female stress urinary incontinence, if conservative management failed. Data comparing the effectiveness and safety of newer single-incision mini-slings with those of standard midurethral slings are limited. METHODS We performed a pragmatic, noninferiority, randomized trial comparing mini-slings with midurethral slings among women at 21 U.K. hospitals during 36 months of follow-up. The primary outcome was patient-reported success (defined as a response of very much or much improved on the Patient Global Impression of Improvement questionnaire) at 15 months after randomization (approximately 1 year after surgery). The noninferiority margin was 10 percentage points. RESULTS A total of 298 women were assigned to receive mini-slings and 298 were assigned to receive midurethral slings. At 15 months, success was reported by 212 of 268 patients (79.1%) in the mini-sling group and by 189 of 250 patients (75.6%) in the midurethral-sling group (adjusted risk difference, 4.6 percentage points; 95% confidence interval [CI], -2.7 to 11.8; P<0.001 for noninferiority). At the 36-month follow-up, success was reported by 177 of 246 patients (72.0%) and by 157 of 235 patients (66.8%) in the respective groups (adjusted risk difference, 5.7 percentage points; 95% CI, -1.3 to 12.8). At 36 months, the percentage of patients with groin or thigh pain was 14.1% with mini-slings and 14.9% with midurethral slings. Over the 36-month follow-up period, the percentage of patients with tape or mesh exposure was 3.3% with mini-slings and 1.9% with midurethral slings, and the percentage who underwent further surgery for stress urinary incontinence was 2.5% and 1.1%, respectively. Outcomes with respect to quality of life and sexual function were similar in the two groups, with the exception of dyspareunia; among 290 women responding to a validated questionnaire, dyspareunia was reported by 11.7% in the mini-sling group and 4.8% in the midurethral-sling group. CONCLUSIONS Single-incision mini-slings were noninferior to standard midurethral slings with respect to patient-reported success at 15 months, and the percentage of patients reporting success remained similar in the two groups at the 36-month follow-up. (Funded by the National Institute for Health Research.).
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Affiliation(s)
- Mohamed Abdel-Fattah
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - David Cooper
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Tracey Davidson
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Mary Kilonzo
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Md Hossain
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Dwayne Boyers
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Kiron Bhal
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Judith Wardle
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - James N'Dow
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - Graeme MacLennan
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
| | - John Norrie
- From the University of Aberdeen, Aberdeen (M.A.-F., D.C., T.D., M.K., M.H., D.B., J. N'Dow, G.M.), University Hospital of Wales, Cardiff (K.B.), Oxford (J.W.), and the University of Edinburgh, Edinburgh (J. Norrie) - all in the United Kingdom
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Dasgupta R, Cameron S, Aucott L, MacLennan G, Kilonzo MM, Lam TBL, Thomas R, Norrie J, McDonald A, Anson K, N’Dow J, Burgess N, Clark CT, Keeley FX, MacLennan SJ, Starr K, McClinton S. Shockwave lithotripsy compared with ureteroscopic stone treatment for adults with ureteric stones: the TISU non-inferiority RCT. Health Technol Assess 2022; 26:1-70. [PMID: 35301982 PMCID: PMC8958411 DOI: 10.3310/wuzw9042] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Urinary stone disease affects 2-3% of the general population. Ureteric stones are associated with severe pain and can have a significant impact on a patient's quality of life. Most ureteric stones are expected to pass spontaneously with supportive care; however, between one-fifth and one-third of patients require an active intervention. The two standard interventions are shockwave lithotripsy and ureteroscopic stone treatment. Both treatments are effective, but they differ in terms of invasiveness, anaesthetic requirement, treatment setting, number of procedures, complications, patient-reported outcomes and cost. There is uncertainty around which is the more clinically effective and cost-effective treatment. OBJECTIVES To determine if shockwave lithotripsy is clinically effective and cost-effective compared with ureteroscopic stone treatment in adults with ureteric stones who are judged to require active intervention. DESIGN A pragmatic, multicentre, non-inferiority, randomised controlled trial of shockwave lithotripsy as a first-line treatment option compared with primary ureteroscopic stone treatment for ureteric stones. SETTING Urology departments in 25 NHS hospitals in the UK. PARTICIPANTS Adults aged ≥ 16 years presenting with a single ureteric stone in any segment of the ureter, confirmed by computerised tomography, who were able to undergo either shockwave lithotripsy or ureteroscopic stone treatment and to complete trial procedures. INTERVENTION Eligible participants were randomised 1 : 1 to shockwave lithotripsy (up to two sessions) or ureteroscopic stone treatment. MAIN OUTCOME MEASURES The primary clinical outcome measure was resolution of the stone episode (stone clearance), which was operationally defined as 'no further intervention required to facilitate stone clearance' up to 6 months from randomisation. This was determined from 8-week and 6-month case report forms and any additional hospital visit case report form that was completed by research staff. The primary economic outcome measure was the incremental cost per quality-adjusted life-year gained at 6 months from randomisation. We estimated costs from NHS resources and calculated quality-adjusted life-years from participant completion of the EuroQol-5 Dimensions, three-level version, at baseline, pre intervention, 1 week post intervention and 8 weeks and 6 months post randomisation. RESULTS In the shockwave lithotripsy arm, 67 out of 302 (22.2%) participants needed further treatment. In the ureteroscopic stone treatment arm, 31 out of 302 (10.3%) participants needed further treatment. The absolute risk difference was 11.4% (95% confidence interval 5.0% to 17.8%); the upper bound of the 95% confidence interval ruled out the prespecified margin of non-inferiority (which was 20%). The mean quality-adjusted life-year difference (shockwave lithotripsy vs. ureteroscopic stone treatment) was -0.021 (95% confidence interval 0.033 to -0.010) and the mean cost difference was -£809 (95% confidence interval -£1061 to -£551). The probability that shockwave lithotripsy is cost-effective is 79% at a threshold of society's willingness to pay for a quality-adjusted life-year of £30,000. The CEAC is derived from the joint distribution of incremental costs and incremental effects. Most of the results fall in the south-west quadrant of the cost effectiveness plane as SWL always costs less but is less effective. LIMITATIONS A limitation of the trial was low return and completion rates of patient questionnaires. The study was initially powered for 500 patients in each arm; however, the total number of patients recruited was only 307 and 306 patients in the ureteroscopic stone treatment and shockwave lithotripsy arms, respectively. CONCLUSIONS Patients receiving shockwave lithotripsy needed more further interventions than those receiving primary ureteroscopic retrieval, although the overall costs for those receiving the shockwave treatment were lower. The absolute risk difference between the two clinical pathways (11.4%) was lower than expected and at a level that is acceptable to clinicians and patients. The shockwave lithotripsy pathway is more cost-effective in an NHS setting, but results in lower quality of life. FUTURE WORK (1) The generic health-related quality-of-life tools used in this study do not fully capture the impact of the various treatment pathways on patients. A condition-specific health-related quality-of-life tool should be developed. (2) Reporting of ureteric stone trials would benefit from agreement on a core outcome set that would ensure that future trials are easier to compare. TRIAL REGISTRATION This trial is registered as ISRCTN92289221. 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. 26, No. 19. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Mary M Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Thomas BL Lam
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Ruth Thomas
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Ken Anson
- Department of Urology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - James N’Dow
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Neil Burgess
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Charles T Clark
- Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK
| | - Francis X Keeley
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | | | - Kath Starr
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Samuel McClinton
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
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Parkes T, Matheson C, Carver H, Foster R, Budd J, Liddell D, Wallace J, Pauly B, Fotopoulou M, Burley A, Anderson I, Price T, Schofield J, MacLennan G. Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study. Harm Reduct J 2022; 19:10. [PMID: 35120539 PMCID: PMC8815224 DOI: 10.1186/s12954-021-00582-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 12/07/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that the development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. METHODS The study used mixed methods to assess the feasibility, acceptability and accessibility of a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning, for people experiencing homelessness and problem substance use. Four Peer Navigators were employed to support individuals (n = 68 total, intervention participants). They were based in outreach services and hostels in Scotland and England. Qualitative interviews were conducted with intervention participants, Peer Navigators and staff in services, and observations were conducted in all settings. Quantitative outcomes relating to participants' substance use, physical and mental health, and quality of the Peer Navigator relationship, were measured via a 'holistic health check' with six questionnaires completed at two time-points. RESULTS The intervention was found to be acceptable to, and feasible and accessible for, participants, Peer Navigators, and service staff. Participants reported improvements to service engagement, and feeling more equipped to access services independently. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling trusting, authentic, and meaningful relationships to be developed. Some challenges were experienced in relation to the 'fit' of the intervention within some settings. Among participants there were reductions in drug use and risky injecting practices. There were increases in the number of participants receiving opioid substitution therapy. Overall, the intervention was positively received, with collective recognition that the intervention was unique and highly valuable. While most of the measures chosen for the holistic health check were found to be suitable for this population, they should be streamlined to avoid duplication and participant burden. CONCLUSIONS The study established that a peer-delivered, relational harm reduction intervention is acceptable to, and feasible and accessible for, people experiencing homelessness and problem substance use. While the study was not outcomes-focused, participants did experience a range of positive outcomes. A full randomised controlled trial is now required to assess intervention effectiveness. TRIAL REGISTRATION Study registered with ISRCTN: 15900054.
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Affiliation(s)
- Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK.
- Faculty of Social Sciences, University of Stirling, Stirling, UK.
| | - Catriona Matheson
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Hannah Carver
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Rebecca Foster
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - John Budd
- Faculty of Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Bernie Pauly
- The Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Maria Fotopoulou
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Isobel Anderson
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Tracey Price
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Joe Schofield
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Graeme MacLennan
- The Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
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Parkes T, Matheson C, Carver H, Foster R, Budd J, Liddell D, Wallace J, Pauly B, Fotopoulou M, Burley A, Anderson I, MacLennan G. A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study. Health Technol Assess 2022; 26:1-128. [PMID: 35212621 PMCID: PMC8899911 DOI: 10.3310/wvvl4786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 01/01/2023] Open
Abstract
BACKGROUND For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues. OBJECTIVES The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial. DESIGN A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures. SETTING The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England. PARTICIPANTS Participants were people experiencing homelessness and problem substance use (n = 68) (intervention). INTERVENTION This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support. MAIN OUTCOME MEASURES Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure. RESULTS The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies. LIMITATIONS Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited. CONCLUSIONS A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention. FUTURE WORK A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments. TRIAL REGISTRATION This trial is registered as ISRCTN15900054. 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. 26, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Catriona Matheson
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Hannah Carver
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Rebecca Foster
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - John Budd
- Faculty of Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Bernie Pauly
- The Canadian Institute for Substance Use Research, University of Victoria, Greater Victoria, BC, Canada
| | - Maria Fotopoulou
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Adam Burley
- Faculty of Medicine, University of Edinburgh, Edinburgh, UK
| | - Isobel Anderson
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Graeme MacLennan
- The Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
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Paterson HM, Cotton S, Norrie J, Nimmo S, Foo I, Balfour A, Speake D, MacLennan G, Stoddart A, Innes K, Cameron S, Aucott L, McCormack K. The ALLEGRO trial: a placebo controlled randomised trial of intravenous lidocaine in accelerating gastrointestinal recovery after colorectal surgery. Trials 2022; 23:84. [PMID: 35090535 PMCID: PMC8795946 DOI: 10.1186/s13063-022-06021-5] [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] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/23/2021] [Indexed: 11/15/2022] Open
Abstract
Background Return of gastrointestinal (GI) function is fundamental to patient recovery after colorectal surgery and is required before patients can be discharged from hospital safely. Up to 40% of patients suffer delayed return of GI function after colorectal surgery, causing nausea, vomiting and abdominal discomfort, resulting in longer hospital stay. Small, randomised studies have suggested perioperative intravenous (IV) lidocaine, which has analgesic and anti-inflammatory effects, may accelerate return of GI function after colorectal surgery. The ALLEGRO trial is a pragmatic effectiveness study to assess the benefit of perioperative IV lidocaine in improving return of GI function after elective minimally invasive (laparoscopic or robotic) colorectal surgery. Methods United Kingdom (UK) multi-centre double blind placebo-controlled randomised controlled trial in 562 patients undergoing elective minimally invasive colorectal resection. IV lidocaine or placebo will be infused for 6–12 h commencing at the start of surgery as an adjunct to usual analgesic/anaesthetic technique. The primary outcome will be return of GI function. Discussion A 6–12-h perioperative intravenous infusion of 2% lidocaine is a cheap addition to usual anaesthetic/analgesic practice in elective colorectal surgery with a low incidence of adverse side-effects. If successful in achieving quicker return of gut function for more patients, it would reduce the rate of postoperative ileus and reduce the duration of inpatient recovery, resulting in reduced pain and discomfort with faster recovery and discharge from hospital. Since colorectal surgery is a common procedure undertaken in every acute hospital in the UK, a reduced length of stay and reduced rate of postoperative ileus would accrue significant cost savings for the National Health Service (NHS). Trial registration EudraCT Number 2017-003835-12; REC Number 17/WS/0210 the trial was prospectively registered (ISRCTN Number: ISRCTN52352431); date of registration 13 June 2018; date of enrolment of first participant 14 August 2018.
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Affiliation(s)
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Susan Nimmo
- Anaesthetics Department, Western General Hospital, Edinburgh, UK
| | - Irwin Foo
- Anaesthetics Department, Western General Hospital, Edinburgh, UK
| | - Angie Balfour
- Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - Doug Speake
- Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Karen Innes
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK.
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
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St Clair D, MacLennan G, Beedie SA, Nouzová E, Lemmon H, Rujescu D, Benson PJ, McIntosh A, Nath M. Eye Movement Patterns Can Distinguish Schizophrenia From the Major Affective Disorders and Healthy Control Subjects. Schizophr Bull Open 2022; 3:sgac032. [PMID: 35669867 PMCID: PMC9155263 DOI: 10.1093/schizbullopen/sgac032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background and hypothesis No objective tests are currently available to help diagnosis of major psychiatric disorders. This study evaluates the potential of eye movement behavior patterns to predict schizophrenia subjects compared to those with major affective disorders and control groups. Study design Eye movements were recorded from a training set of UK subjects with schizophrenia (SCZ; n = 120), bipolar affective disorder (BPAD; n = 141), major depressive disorder (MDD; n = 136), and healthy controls (CON; n = 142), and from a hold-out set of 133 individuals with proportional group sizes. A German cohort of SCZ (n = 60) and a Scottish cohort of CON subjects (n = 184) acted as a second semi-independent test set. All patients met DSMIV and ICD10 criteria for SCZ, BPAD, and MDD. Data from 98 eye movement features were extracted. We employed a gradient boosted (GB) decision tree multiclass classifier to develop a predictive model. We calculated the area under the curve (AUC) as the primary performance metric. Study results Estimates of AUC in one-versus-all comparisons were: SCZ (0.85), BPAD (0.78), MDD (0.76), and CON (0.85). Estimates on part-external validation were SCZ (0.89) and CON (0.65). In all cases, there was good specificity but only moderate sensitivity. The best individual discriminators included free viewing, fixation duration, and smooth pursuit tasks. The findings appear robust to potential confounders such as age, sex, medication, or mental state at the time of testing. Conclusions Eye movement patterns can discriminate schizophrenia from major mood disorders and control subjects with around 80% predictive accuracy.
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Affiliation(s)
- David St Clair
- Division of Applied Medicine, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Sara A Beedie
- Clinical Research Centre, Royal Cornhill Hospital, Aberdeen, UK
| | - Eva Nouzová
- Clinical Research Centre, Royal Cornhill Hospital, Aberdeen, UK
| | - Helen Lemmon
- Clinical Research Centre, Royal Cornhill Hospital, Aberdeen, UK
| | - Dan Rujescu
- Department of Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Philip J Benson
- Department of Psychology, University of Aberdeen, Aberdeen, UK
| | - Andrew McIntosh
- Division of Psychiatry, Royal Edinburgh Hospital , Edinburgh, UK
| | - Mintu Nath
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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King AJ, Fernie G, Hudson J, Kernohan A, Azuara-Blanco A, Burr J, Homer T, Shabaninejad H, Sparrow JM, Garway-Heath D, Barton K, Norrie J, McDonald A, Vale L, MacLennan G. Primary trabeculectomy versus primary glaucoma eye drops for newly diagnosed advanced glaucoma: TAGS RCT. Health Technol Assess 2021; 25:1-158. [PMID: 34854808 DOI: 10.3310/hta25720] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients diagnosed with advanced primary open-angle glaucoma are at a high risk of lifetime blindness. Uncertainty exists about whether primary medical management (glaucoma eye drops) or primary surgical treatment (augmented trabeculectomy) provide the best and safest patient outcomes. OBJECTIVES To compare primary medical management with primary surgical treatment (augmented trabeculectomy) in patients with primary open-angle glaucoma presenting with advanced disease in terms of health-related quality of life, clinical effectiveness, safety and cost-effectiveness. DESIGN This was a two-arm, parallel, multicentre, pragmatic randomised controlled trial. SETTING Secondary care eye services. PARTICIPANTS Adult patients presenting with advanced primary open-angle glaucoma in at least one eye, as defined by the Hodapp-Parrish-Anderson classification of severe glaucoma. INTERVENTION Primary medical treatment - escalating medical management with glaucoma eye drops. Primary trabeculectomy treatment - trabeculectomy augmented with mitomycin C. MAIN OUTCOME MEASURES The primary outcome was health-related quality of life measured with the Visual Function Questionnaire-25 at 2 years post randomisation. Secondary outcomes were mean intraocular pressure; EQ-5D-5L; Health Utilities Index 3; Glaucoma Utility Index; cost and cost-effectiveness; generic, vision-specific and disease-specific health-related quality of life; clinical effectiveness; and safety. RESULTS A total of 453 participants were recruited. The mean age of the participants was 67 years (standard deviation 12 years) in the trabeculectomy arm and 68 years (standard deviation 12 years) in the medical management arm. Over 65% of participants were male and more than 80% were white. At 24 months, the mean difference in Visual Function Questionnaire-25 score was 1.06 (95% confidence interval -1.32 to 3.43; p = 0.383). There was no evidence of a difference between arms in the EQ-5D-5L score, the Health Utilities Index or the Glaucoma Utility Index. At 24 months, the mean intraocular pressure was 12.40 mmHg in the trabeculectomy arm and 15.07 mmHg in the medical management arm (mean difference -2.75 mmHg, 95% confidence interval -3.84 to -1.66 mmHg; p < 0.001). Fewer types of glaucoma eye drops were required in the trabeculectomy arm. LogMAR visual acuity was slightly better in the medical management arm (mean difference 0.07, 95% confidence interval 0.02 to 0.11; p = 0.006) than in the trabeculectomy arm. There was no evidence of difference in safety between the two arms. A discrete choice experiment updated the utility values for the Glaucoma Utility Index. The within-trial economic analysis found a small increase in the mean EQ-5D-5L score (0.04) and that trabeculectomy has a higher probability of being cost-effective than medical management. The incremental cost of trabeculectomy per quality-adjusted life-year was £45,456. Therefore, at 2 years, surgery is unlikely to be considered cost-effective at a threshold of £20,000 per quality-adjusted life-year. When extrapolated over a patient's lifetime in a model-based analysis, trabeculectomy, compared with medical treatment, was associated with higher costs (average £2687), a larger number of quality-adjusted life-years (average 0.28) and higher incremental cost per quality-adjusted life-year gained (average £9679). The likelihood of trabeculectomy being cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life year gained was 73%. CONCLUSIONS Our results suggested that there was no difference between treatment arms in health-related quality of life, as measured with the Visual Function Questionnaire-25 at 24 months. Intraocular pressure was better controlled in the trabeculectomy arm, and this may reduce visual field progression. Modelling over the patient's lifetime suggests that trabeculectomy may be cost-effective over the range of values of society's willingness to pay for a quality-adjusted life-year. FUTURE WORK Further follow-up of participants will allow us to estimate the long-term differences of disease progression, patient experience and cost-effectiveness. TRIAL REGISTRATION Current Controlled Trials ISRCTN56878850. 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. 25, No. 72. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony J King
- Department of Ophthalmology, Nottingham University Hospital, Nottingham, UK
| | - Gordon Fernie
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ashleigh Kernohan
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Jennifer Burr
- School of Medicine, Medical and Biological Sciences, University of St Andrews, St Andrews, UK
| | - Tara Homer
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hosein Shabaninejad
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John M Sparrow
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David Garway-Heath
- Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Abdel-Fattah M, Chapple C, Guerrero K, Dixon S, Cotterill N, Ward K, Hashim H, Monga A, Brown K, Drake MJ, Gammie A, Mostafa A, Bladder Health UK, Breeman S, Cooper D, MacLennan G, Norrie J. Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms. Trials 2021; 22:745. [PMID: 34702331 PMCID: PMC8546752 DOI: 10.1186/s13063-021-05661-3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 09/24/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only. METHODS FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs. DISCUSSION The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective. TRIAL REGISTRATION ISRCTN63268739 . Registered on 14 September 2017.
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Affiliation(s)
- M Abdel-Fattah
- Aberdeen Centre for Women's Health Research, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
| | - C Chapple
- Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - K Guerrero
- Department of Urogynaecology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - S Dixon
- Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - N Cotterill
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Ward
- Warrell Unit, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - H Hashim
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - A Monga
- Department of Gynaecology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - K Brown
- Department of Gynaecology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - M J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - A Gammie
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - A Mostafa
- Aberdeen Centre for Women's Health Research, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - S Breeman
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - D Cooper
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - G MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - J Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
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Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK. Total versus partial knee replacement in patients with medial compartment knee osteoarthritis: the TOPKAT RCT. Health Technol Assess 2021; 24:1-98. [PMID: 32369436 DOI: 10.3310/hta24200] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Late-stage medial compartment knee osteoarthritis can be treated using total knee replacement or partial (unicompartmental) knee replacement. There is high variation in treatment choice and insufficient evidence to guide selection. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of partial knee replacement compared with total knee replacement in patients with medial compartment knee osteoarthritis. The findings are intended to guide surgical decision-making for patients, surgeons and health-care providers. DESIGN This was a randomised, multicentre, pragmatic comparative effectiveness trial that included an expertise component. The target sample size was 500 patients. A web-based randomisation system was used to allocate treatments. SETTING Twenty-seven NHS hospitals (68 surgeons). PARTICIPANTS Patients with medial compartment knee osteoarthritis. INTERVENTIONS The trial compared the overall management strategy of partial knee replacement treatment with total knee replacement treatment. No specified brand or subtype of implant was investigated. MAIN OUTCOME MEASURES The Oxford Knee Score at 5 years was the primary end point. Secondary outcomes included activity scores, global health measures, transition items, patient satisfaction (Lund Score) and complications (including reoperation, revision and composite 'failure' - defined by minimal Oxford Knee Score improvement and/or reoperation). Cost-effectiveness was also assessed. RESULTS A total of 528 patients were randomised (partial knee replacement, n = 264; total knee replacement, n = 264). The follow-up primary outcome response rate at 5 years was 88% and both operations had good outcomes. There was no significant difference between groups in mean Oxford Knee Score at 5 years (difference 1.04, 95% confidence interval -0.42 to 2.50). An area under the curve analysis of the Oxford Knee Score at 5 years showed benefit in favour of partial knee replacement over total knee replacement, but the difference was within the minimal clinically important difference [mean 36.6 (standard deviation 8.3) (n = 233), mean 35.1 (standard deviation 9.1) (n = 231), respectively]. Secondary outcome measures showed consistent patterns of benefit in the direction of partial knee replacement compared with total knee replacement although most differences were small and non-significant. Patient-reported improvement (transition) and reflection (would you have the operation again?) showed statistically significant superiority for partial knee replacement only, but both of these variables could be influenced by the lack of blinding. The frequency of reoperation (including revision) by treatment received was similar for both groups: 22 out of 245 for partial knee replacement and 28 out of 269 for total knee replacement patients. Revision rates at 5 years were 10 out of 245 for partial knee replacement and 8 out of 269 for total knee replacement. There were 28 'failures' of partial knee replacement and 38 'failures' of total knee replacement (as defined by composite outcome). Beyond 1 year, partial knee replacement was cost-effective compared with total knee replacement, being associated with greater health benefits (measured using quality-adjusted life-years) and lower health-care costs, reflecting lower costs of the index surgery and subsequent health-care use. LIMITATIONS It was not possible to blind patients in this study and there was some non-compliance with the allocated treatment interventions. Surgeons providing partial knee replacement were relatively experienced with the procedure. CONCLUSIONS Both total knee replacement and partial knee replacement are effective, offer similar clinical outcomes and have similar reoperation and complication rates. Some patient-reported measures of treatment approval were significantly higher for partial knee replacement than for total knee replacement. Partial knee replacement was more cost-effective (more effective and cost saving) than total knee replacement at 5 years. FUTURE WORK Further (10-year) follow-up is in progress to assess the longer-term stability of these findings. TRIAL REGISTRATION Current Controlled Trials ISRCTN03013488 and ClinicalTrials.gov NCT01352247. 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. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Loretta J Davies
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Seamus Kent
- Department of Public Health, University of Oxford, Oxford, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jose Leal
- Department of Public Health, University of Oxford, Oxford, UK
| | - Helen Campbell
- Department of Public Health, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Department of Public Health, University of Oxford, Oxford, UK
| | - Nigel Arden
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - David Murray
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
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Clarkson JE, Ramsay CR, Ricketts D, Banerjee A, Deery C, Lamont T, Boyers D, Marshman Z, Goulao B, Banister K, Conway D, Dawett B, Baker S, Sherriff A, Young L, van der Pol M, MacLennan G, Floate R, Braid H, Fee P, Forrest M, Gouick J, Mitchell F, Gupta E, Dakri R, Kettle J, McGuff T, Dunn K. Selective Caries Removal in Permanent Teeth (SCRiPT) for the treatment of deep carious lesions: a randomised controlled clinical trial in primary care. BMC Oral Health 2021; 21:336. [PMID: 34243733 PMCID: PMC8267238 DOI: 10.1186/s12903-021-01637-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/04/2020] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Dental caries is one of the most prevalent non-communicable disease globally and can have serious health sequelae impacting negatively on quality of life. In the UK most adults experience dental caries during their lifetime and the 2009 Adult Dental Health Survey reported that 85% of adults have at least one dental restoration. Conservative removal of tooth tissue for both primary and secondary caries reduces the risk of failure due to tooth-restoration, complex fracture as well as remaining tooth surfaces being less vulnerable to further caries. However, despite its prevalence there is no consensus on how much caries to remove prior to placing a restoration to achieve optimal outcomes. Evidence for selective compared to complete or near-complete caries removal suggests there may be benefits for selective removal in sustaining tooth vitality, therefore avoiding abscess formation and pain, so eliminating the need for more complex and costly treatment or eventual tooth loss. However, the evidence is of low scientific quality and mainly gleaned from studies in primary teeth. METHOD This is a pragmatic, multi-centre, two-arm patient randomised controlled clinical trial including an internal pilot set in primary dental care in Scotland and England. Dental health professionals will recruit 623 participants over 12-years of age with deep carious lesions in their permanent posterior teeth. Participants will have a single tooth randomised to either the selective caries removal or complete caries removal treatment arm. Baseline measures and outcome data (during the 3-year follow-up period) will be assessed through clinical examination, patient questionnaires and NHS databases. A mixed-method process evaluation will complement the clinical and economic outcome evaluation and examine implementation, mechanisms of impact and context. The primary outcome at three years is sustained tooth vitality. The primary economic outcome is net benefit modelled over a lifetime horizon. Clinical secondary outcomes include pulp exposure, progession of caries, restoration failure; as well as patient-centred and economic outcomes. DISCUSSION SCRiPT will provide evidence for the most clinically effective and cost-beneficial approach to managing deep carious lesions in permanent posterior teeth in primary care. This will support general dental practitioners, patients and policy makers in decision making. Trial Registration Trial registry: ISRCTN. TRIAL REGISTRATION NUMBER ISRCTN76503940. Date of Registration: 30.10.2019. URL of trial registry record: https://www.isrctn.com/ISRCTN76503940?q=ISRCTN76503940%20&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search .
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Affiliation(s)
- Jan E Clarkson
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK.,NHS Education for Scotland, Edinburgh, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Ricketts
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Avijit Banerjee
- Faculty of Dentistry, Oral and Craniofacial Services, Kings College London, London, UK
| | - Chris Deery
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Thomas Lamont
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK.
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zoe Marshman
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Banister
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Conway
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Bhupinder Dawett
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK.,Hafren House Dental Practice, Alfreton, Derbyshire, UK
| | - Sarah Baker
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Andrea Sherriff
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ruth Floate
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Hazel Braid
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Patrick Fee
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jill Gouick
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Fiona Mitchell
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Ekta Gupta
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Riz Dakri
- Faculty of Dentistry, Oral and Craniofacial Services, Kings College London, London, UK
| | - Jennifer Kettle
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Tina McGuff
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
| | - Katharine Dunn
- Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK
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43
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Norman JE, Norrie J, MacLennan G, Cooper D, Whyte S, Chowdhry S, Cunningham-Burley S, Neilson AR, Mei XW, Smith JB, Shennan A, Robson SC, Thornton S, Kilby MD, Marlow N, Stock SJ, Bennett PR, Denton J. The Arabin pessary to prevent preterm birth in women with a twin pregnancy and a short cervix: the STOPPIT 2 RCT. Health Technol Assess 2021; 25:1-66. [PMID: 34219633 DOI: 10.3310/hta25440] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Preterm birth is common in twins and accounts for significant mortality and morbidity. There are no effective preventative treatments. Some studies have suggested that, in twin pregnancy complicated by a short cervix, the Arabin pessary, which fits around the cervix and can be inserted as an outpatient procedure, reduces preterm birth and prevents neonatal morbidity. OBJECTIVE STOPPIT 2 aimed to evaluate the clinical utility of the Arabin cervical pessary in preventing preterm birth in women with a twin pregnancy and a short cervix. DESIGN STOPPIT 2 was a pragmatic, open label, multicentre randomised controlled trial with two treatment group - the Arabin pessary plus standard care (intervention) and standard care alone (control). Participants were initially recruited into the screening phase of the study, when cervical length was measured. Women with a measured cervical length of ≤ 35 mm were then recruited into the treatment phase of the study. An economic evaluation considered cost-effectiveness and a qualitative substudy explored the experiences of participants and clinicians. SETTING Antenatal clinics in the UK and elsewhere in Europe. PARTICIPANTS Women with twin pregnancy at < 21 weeks' gestation with known chorionicity and gestation established by scan at ≤ 16 weeks' gestation. INTERVENTIONS Ultrasound scan to establish cervical length. Women with a cervical length of ≤ 35 mm at 18+ 0-20+ 6 weeks' gestation were randomised to standard care or Arabin pessary plus standard care. Randomisation was performed by computer and accessed through a web-based browser. MAIN OUTCOME MEASURES Obstetric - all births before 34+ 0 weeks' gestation following the spontaneous onset of labour; and neonatal - composite of adverse outcomes, including stillbirth or neonatal death, periventricular leukomalacia, early respiratory morbidity, intraventricular haemorrhage, necrotising enterocolitis or proven sepsis, all measured up to 28 days after the expected date of delivery. RESULTS A total of 2228 participants were recruited to the screening phase, of whom 2170 received a scan and 503 were randomised: 250 to Arabin pessary and 253 to standard care alone. The rate of the primary obstetric outcome was 18.4% (46/250) in the intervention group and 20.6% (52/253) in the control group (adjusted odds ratio 0.87, 95% confidence interval 0.55 to 1.38; p = 0.54). The rate of the primary neonatal outcome was 13.4% (67/500) and 15.0% (76/506) in the intervention group and control group, respectively (adjusted odds ratio 0.86, 95% confidence interval 0.54 to 1.36; p = 0.52). The pessary was largely well tolerated and clinicians found insertion and removal 'easy' or 'fairly easy' in the majority of instances. The simple costs analysis showed that pessary treatment is no more costly than standard care. LIMITATIONS There was the possibility of a type II error around smaller than anticipated benefit. CONCLUSIONS In this study, the Arabin pessary did not reduce preterm birth or adverse neonatal outcomes in women with a twin pregnancy and a short cervix. The pessary either is ineffective at reducing preterm birth or has an effect size of < 0.4. FUTURE WORK Women with twin pregnancy remain at risk of preterm birth; work is required to find treatments for this. TRIAL REGISTRATION Current Controlled Trials ISRCTN98835694 and ClinicalTrials.gov NCT02235181. 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. 25, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Sonia Whyte
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | | | | | | | - Xue W Mei
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Joel Be Smith
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Shennan
- Tommy's London Research Centre, King's College London, London, UK
| | - Stephen C Robson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Thornton
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark D Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust and College of Medical and Dental Science, University of Birmingham, Birmingham, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Sarah J Stock
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Philip R Bennett
- Department of Surgery and Cancer, Imperial College London, London, UK
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44
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Booth J, Aucott L, Cotton S, Davis B, Fenocchi L, Goodman C, Hagen S, Harari D, Lawrence M, Lowndes A, Macaulay L, MacLennan G, Mason H, McClurg D, Norrie J, Norton C, O'Dolan C, Skelton D, Surr C, Treweek S. Tibial nerve stimulation compared with sham to reduce incontinence in care home residents: ELECTRIC RCT. Health Technol Assess 2021; 25:1-110. [PMID: 34167637 PMCID: PMC8273680 DOI: 10.3310/hta25410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Urinary incontinence is prevalent in nursing and residential care homes, and has a profound impact on residents' dignity and quality of life. Treatment options are limited in these care contexts and care homes predominantly use absorbent pads to contain incontinence, rather than actively treat it. Transcutaneous posterior tibial nerve stimulation is a non-invasive, safe, low-cost intervention that is effective in reducing urinary incontinence in adults. OBJECTIVE To determine the clinical effectiveness of transcutaneous posterior tibial nerve stimulation to treat urinary incontinence in care home residents and to determine the associated costs of the treatment. DESIGN A multicentre, pragmatic, participant and outcome assessor-blind, randomised placebo-controlled trial. SETTING A total of 37 UK residential and nursing care homes. PARTICIPANTS Care home residents with at least weekly urinary incontinence that is contained using absorbent pads and who are able to use a toilet/toilet aid with or without assistance. INTERVENTIONS Residents were randomised (1 : 1) to receive 12 30-minute sessions of transcutaneous posterior tibial nerve stimulation or sham stimulation over a 6-week period. MAIN OUTCOME MEASURES Primary outcome - change in volume of urine leaked over a 24-hour period at 6 weeks. Secondary outcomes - number of pads used, Perception of Bladder Condition, toileting skills, quality of life and resource use. RESULTS A total of 408 residents were randomised (transcutaneous posterior tibial nerve stimulation, n = 197; sham stimulation, n = 209); two exclusions occurred post randomisation. Primary outcome data were available for 345 (85%) residents (transcutaneous posterior tibial nerve stimulation, n = 167; sham stimulation, n = 178). Adherence to the intervention protocol was as follows: 78% of the transcutaneous posterior tibial nerve stimulation group and 71% of the sham group received the correct stimulation. Primary intention-to-treat adjusted analysis indicated a mean change of -5 ml (standard deviation 362 ml) urine leakage from baseline in the transcutaneous posterior tibial nerve stimulation group and -66 ml (standard deviation 394 ml) urine leakage in the sham group, which was a statistically significant, but not clinically important, between-group difference of 68-ml urine leakage (95% confidence interval 0 to 136 ml; p = 0.05) in favour of the sham group. Sensitivity analysis supported the primary analysis. No meaningful differences were detected in any of the secondary outcomes. No serious adverse events related to transcutaneous posterior tibial nerve stimulation were reported. Economic evaluation assessed the resources used. The training and support costs for the staff to deliver the intervention were estimated at £121.03 per staff member. Estimated costs for delivery of transcutaneous posterior tibial nerve stimulation during the trial were £81.20 per participant. No significant difference was found between participants' scores over time, or between transcutaneous posterior tibial nerve stimulation and sham groups at any time point, for resident or proxy quality-of-life measures. CONCLUSIONS The ELECTRIC (ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes) trial showed, in the care home context (with a high proportion of residents with poor cognitive capacity and limited independent mobility), that transcutaneous posterior tibial nerve stimulation was not effective in reducing urinary incontinence. No economic case for transcutaneous posterior tibial nerve stimulation was made by the cost-consequences analysis; however, the positive reception of learning about urinary incontinence for care home staff supports a case for routine education in this care context. LIMITATIONS Completing 24-hour pad collections was challenging for care home staff, resulting in some missing primary outcome data. FUTURE WORK Research should investigate transcutaneous posterior tibial nerve stimulation in residents with urgency urinary incontinence to determine whether or not targeted stimulation is effective. Research should evaluate the effects of continence training for staff on continence care in care homes. TRIAL REGISTRATION Current Controlled Trials ISRCTN98415244 and ClinicalTrials.gov NCT03248362. 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. 25, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Booth
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lorna Aucott
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Bridget Davis
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Linda Fenocchi
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Danielle Harari
- Department of Geriatric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Maggie Lawrence
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Lisa Macaulay
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Helen Mason
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Catriona O'Dolan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Dawn Skelton
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Claire Surr
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Shaun Treweek
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
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45
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Abrams P, Constable LD, Cooper D, MacLennan G, Drake MJ, Harding C, Mundy A, McCormack K, McDonald A, Norrie J, Ramsay C, Smith R, Cotterill N, Kilonzo M, Glazener C. Outcomes of a Noninferiority Randomised Controlled Trial of Surgery for Men with Urodynamic Stress Incontinence After Prostate Surgery (MASTER). Eur Urol 2021; 79:812-823. [PMID: 33551297 PMCID: PMC8175331 DOI: 10.1016/j.eururo.2021.01.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/17/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Stress urinary incontinence (SUI) is common after radical prostatectomy and likely to persist despite conservative treatment. The sling is an emerging operation for persistent SUI, but randomised controlled trial (RCT) comparison with the established artificial urinary sphincter (AUS) is lacking. OBJECTIVE To compare the outcomes of surgery in men with bothersome urodynamic SUI after prostate surgery. DESIGN, SETTING, AND PARTICIPANTS A noninferiority RCT was conducted among men with bothersome urodynamic SUI from 27 UK centres. Blinding was not possible due the surgeries. INTERVENTION Participants were randomly assigned (1:1) to the male transobturator sling (n = 190) or the AUS (n = 190) group. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was patient-reported SUI 12 mo after randomisation, collected from postal questionnaire using a composite outcome from two items in validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire (ICIQ-UI SF). Noninferiority margin was 15%, thought to be of acceptable lower effectiveness, in return for reduced adverse events (AEs) and easier operation, for the sling. Secondary outcomes were operative and postoperative details, patient-reported measures, and AEs, up to 12 mo after surgery. RESULTS AND LIMITATIONS A total of 380 participants were included. At 12 mo after randomisation, incontinence rates were 134/154 (87.0%) for male sling versus 133/158 (84.2%) for AUS (difference 3.6% [95% confidence interval {CI} -11.6 to 4.6], pNI = 0.003), showing noninferiority. Incontinence symptoms (ICIQ-UI SF) reduced from scores of 16.1 and 16.4 at baseline to 8.7 and 7.5 for male sling and AUS, respectively (mean difference 1.4 [95% CI 0.2-2.6], p = 0.02). Serious AEs (SAEs) were few: n = 6 and n = 13 for male sling and AUS (one man had three SAEs), respectively. Quality of life scores improved, and satisfaction was high in both groups. All other secondary outcomes that show statistically significant differences favour the AUS. CONCLUSIONS Using a strict definition, urinary incontinence rates remained high, with no evidence of difference between male sling and AUS. Symptoms and quality of life improved significantly in both groups, and men were generally satisfied with both procedures. Overall, secondary and post hoc analyses were in favour of AUS. PATIENT SUMMARY Urinary incontinence after prostatectomy has considerable effect on men's quality of life. MASTER shows that if surgery is needed, both surgical options result in fewer symptoms and high satisfaction, despite most men not being completely dry. However, most other results indicate that men having an artificial urinary sphincter have better outcomes than those who have a sling.
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Affiliation(s)
- Paul Abrams
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Lynda D Constable
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK.
| | - David Cooper
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Marcus J Drake
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Chris Harding
- Department of Urology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Anthony Mundy
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kirsty McCormack
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Alison McDonald
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Craig Ramsay
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Rebecca Smith
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Nikki Cotterill
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; Faculty of Health and Applied Science, University of West of England, Bristol, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cathryn Glazener
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
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46
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Khadhouri S, Gallagher KM, MacKenzie KR, Shah TT, Gao C, Moore S, Zimmermann EF, Edison E, Jefferies M, Nambiar A, Mannas MP, Lee T, Marra G, Lillaz B, Gómez Rivas J, Olivier J, Assmus MA, Uçar T, Claps F, Boltri M, Burnhope T, Nkwam N, Tanasescu G, Boxall NE, Downey AP, Lal AA, Antón-Juanilla M, Clarke H, Lau DHW, Gillams K, Crockett M, Nielsen M, Takwoingi Y, Chuchu N, O'Rourke J, MacLennan G, McGrath JS, Kasivisvanathan V. The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study. BJU Int 2021; 128:440-450. [PMID: 33991045 DOI: 10.1111/bju.15483] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 02/26/2021] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. PATIENTS AND METHODS This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. RESULTS Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3-34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1-30.2), UTUC (n = 128) 1.14% (95% CI 0.77-1.52), renal cancer (n = 107) 1.05% (95% CI 0.80-1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32-2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03-1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90-4.15; P < 0.001), male sex 1.30 (95% CI 1.14-1.50; P < 0.001), and smoking 2.70 (95% CI 2.30-3.18; P < 0.001). CONCLUSIONS A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer.
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Affiliation(s)
- Sinan Khadhouri
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Aberdeen Royal Infirmary, Aberdeen, UK.,British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK
| | - Kevin M Gallagher
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Department of Clinical Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Kenneth R MacKenzie
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Freeman Hospital, Newcastle Upon Tyne, UK
| | - Taimur T Shah
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Dept. of Surgery and Cancer, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Chuanyu Gao
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sacha Moore
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Wrexham Maelor Hospital, Wrexham, UK
| | - Eleanor F Zimmermann
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Torbay and South Devon NHS Foundation Trust, Torbay, UK
| | - Eric Edison
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Department of Urology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Matthew Jefferies
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Morriston Hospital, Swansea, UK
| | - Arjun Nambiar
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Freeman Hospital, Newcastle Upon Tyne, UK
| | - Miles P Mannas
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Taeweon Lee
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Giancarlo Marra
- Department of Surgical Sciences, Città della Salute e della Scienza, Turin, Italy.,University of Turin, Turin, Italy
| | | | - Juan Gómez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain
| | - Jonathan Olivier
- Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France
| | - Mark A Assmus
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Taha Uçar
- Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Francesco Claps
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Matteo Boltri
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Tara Burnhope
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nkwam Nkwam
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | | | | | - Asim A Lal
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | | | - Holly Clarke
- Bradford Teaching Hospitals, NHS Foundation Trust, Bradford, UK
| | | | | | - Matthew Crockett
- Frimley Renal Cancer Centre, Frimley Hospitals NHS Foundation Trust, Camberley, UK
| | - Matthew Nielsen
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Naomi Chuchu
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - John O'Rourke
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John S McGrath
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Veeru Kasivisvanathan
- British Urology Researchers in Surgical Training (BURST) Collaborative, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
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47
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King AJ, Hudson J, Fernie G, Kernohan A, Azuara-Blanco A, Burr J, Homer T, Shabaninejad H, Sparrow JM, Garway-Heath D, Barton K, Norrie J, McDonald A, Vale L, MacLennan G. Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS). BMJ 2021; 373:n1014. [PMID: 33980505 PMCID: PMC8114777 DOI: 10.1136/bmj.n1014] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma. DESIGN Pragmatic multicentre randomised controlled trial. SETTING 27 secondary care glaucoma departments in the UK. PARTICIPANTS 453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017. INTERVENTIONS Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months. SECONDARY OUTCOMES general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety. RESULTS At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare. CONCLUSION Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication. TRIAL REGISTRATION Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.
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Affiliation(s)
- Anthony J King
- Department of Ophthalmology, Nottingham University Hospital, Nottingham, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gordon Fernie
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, UK
| | - Ashleigh Kernohan
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Augusto Azuara-Blanco
- Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital, Belfast, UK
| | - Jennifer Burr
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Tara Homer
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hosein Shabaninejad
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John M Sparrow
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David Garway-Heath
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, UK
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48
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Dasgupta R, Cameron S, Aucott L, MacLennan G, Thomas RE, Kilonzo MM, Lam TBL, N'Dow J, Norrie J, Anson K, Burgess N, Clark CT, Keeley FX, MacLennan SJ, Starr K, McClinton S. Shockwave Lithotripsy Versus Ureteroscopic Treatment as Therapeutic Interventions for Stones of the Ureter (TISU): A Multicentre Randomised Controlled Non-inferiority Trial. Eur Urol 2021; 80:46-54. [PMID: 33810921 PMCID: PMC8234516 DOI: 10.1016/j.eururo.2021.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 08/09/2020] [Accepted: 02/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Renal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways. OBJECTIVE To report a pragmatic multicentre non-inferiority RCT comparing SWL with URS. DESIGN, SETTING, AND PARTICIPANTS This trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned. RESULTS AND LIMITATIONS The study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL. CONCLUSIONS This RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition. PATIENT SUMMARY We present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition.
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Affiliation(s)
- Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Ruth E Thomas
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Mary M Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Thomas B L Lam
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - James N'Dow
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK
| | - Ken Anson
- Department of Urology, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Neil Burgess
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Charles T Clark
- Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK
| | - Francis X Keeley
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Sara J MacLennan
- Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Kath Starr
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, UK
| | - Sam McClinton
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
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49
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Ahmed I, Innes K, Brazzelli M, Gillies K, Newlands R, Avenell A, Hernández R, Blazeby J, Croal B, Hudson J, MacLennan G, McCormack K, McDonald A, Murchie P, Ramsay C. Protocol for a randomised controlled trial comparing laparoscopic cholecystectomy with observation/conservative management for preventing recurrent symptoms and complications in adults with uncomplicated symptomatic gallstones (C-Gall trial). BMJ Open 2021; 11:e039781. [PMID: 33766835 PMCID: PMC7996370 DOI: 10.1136/bmjopen-2020-039781] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 12/26/2022] Open
Abstract
BACKGROUND Gallstone disease (cholelithiasis) is common. In most people it is asymptomatic and does not require treatment, but in about 20% it can become symptomatic, causing pain and other complications requiring medical attention and/or surgery. A proportion of symptomatic people with uncomplicated gallstone disease do not experience further episodes of pain and, therefore, could be treated conservatively. Moreover, surgery carries risks of perioperative and postoperative complications. METHODS AND ANALYSIS C-Gall is a pragmatic, multicentre, randomised controlled trial and economic evaluation to assess whether cholecystectomy is cost-effective compared with observation/ conservative management (here after referred to as medical management) at 18 months post-randomisation (with internal pilot). PRIMARY OUTCOME MEASURE Patient-reported quality of life (QoL) (36-Item Short Form Survey (SF-36) bodily pain domain) up to 18 months after randomisation.The primary economic outcome is incremental cost per quality-adjusted life year gained at 18 months. SECONDARY OUTCOME MEASURES Secondary outcome measures include condition-specific QoL, SF-36 domains, complications, further treatment, persistent symptoms, healthcare resource use, and costs assessed at 18 and 24 months after randomisation. The bodily pain domain of the SF-36 will also be assessed at 24 months after randomisation.A sample size of 430 participants was calculated. Computer-generated 1:1 randomisation was used.The C-Gall Study is currently in follow-up in 20 UK research centres. The first patient was randomised on 1 August 2016, with follow-up to be completed by 30 November 2021. STATISTICAL ANALYSIS Statistical analysis of the primary outcome will be intention-to-treat and a per-protocol analysis. The primary outcome, area under the curve (AUC) for the SF-36 bodily pain up to 18 months, will be generated using the Trapezium rule and analysed using linear regression with adjustment for the minimisation variables (recruitment site, sex and age). For the secondary outcome, SF-36 bodily pain, AUC up to 24 months will be analysed in a similar way. Other secondary outcomes will be analysed using generalised linear models with adjustment for minimisation and baseline variables, as appropriate. Statistical significance will be at the two-sided 5% level with corresponding CIs. ETHICS AND DISSEMINATION The North of Scotland Research Ethics Committee approved this study (16/NS/0053). The dissemination plans include Health Technology Assessment monograph, international scientific meetings and publications in high-impact, open-access journals. TRIAL REGISTRATION NUMBER ISRCTN55215960; pre-results.
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Affiliation(s)
- Irfan Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Karen Innes
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Rumana Newlands
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Alison Avenell
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit (HERU), University of Aberdeen, Aberdeen, UK
| | - Jane Blazeby
- Centre for Surgical Research and NIHR Bristol and Weston Biomedical Research Centre, University of Bristol, Bristol, UK
| | | | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Alison McDonald
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen Health Services Research Unit, Aberdeen, UK
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50
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Newlands R, Duncan E, Presseau J, Treweek S, Lawrie L, Bower P, Elliott J, Francis J, MacLennan G, Ogden M, Wells M, Witham MD, Young B, Gillies K. Why trials lose participants: A multitrial investigation of participants' perspectives using the theoretical domains framework. J Clin Epidemiol 2021; 137:1-13. [PMID: 33727134 DOI: 10.1016/j.jclinepi.2021.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 10/31/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To use the Theoretical Domains Framework (TDF) to identify barriers and enablers to participant retention in trials requiring questionnaire return and/or attendance at follow-up clinics. STUDY DESIGN AND SETTING We invited participants (n = 607) from five pragmatic effectiveness trials, who missed at least one follow-up time point (by not returning a questionnaire and/or not attending a clinic visit), to take part in semistructured telephone interviews. The TDF informed both data collection and analysis. To establish what barriers and enablers most likely influence the target behavior the domain relevance threshold was set at >75% of participants mentioning the domain. RESULTS Sixteen participants (out of 25 showing interest) were interviewed. Overall, seven theoretical domains were identified as both barriers and enablers to the target behaviors of attending clinic appointments and returning postal questionnaires. Barriers frequently reported in relation to both target behaviours stemmed from participants' knowledge, beliefs about their capabilities and the consequences of performing (or not performing) the behavior. Two domains were identified as salient for questionnaire return only: goals; and memory, attention and decision-making. Emotion was identified as relevant for clinic attendance only. CONCLUSION This is the first study informed by behavioural science to explore trial participants' accounts of trial retention. Findings will serve as a guiding framework when designing trials to limit barriers and enhance enablers of retention within clinical trials.
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Affiliation(s)
- Rumana Newlands
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Eilidh Duncan
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; School of Psychology, University of Ottawa, Ottawa, Canada
| | - Shaun Treweek
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Louisa Lawrie
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Jim Elliott
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK; Public Partner
| | - Jill Francis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Graeme MacLennan
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Margaret Ogden
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK; Public Partner
| | - Mary Wells
- Faculty of Medicine, Department of Surgery and Cancer, Imperial College, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Miles D Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK.
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