Impact of nationwide enhanced implementation of best practices in pancreatic cancer care (PACAP-1): a multicenter stepped-wedge cluster randomized controlled trial

Background

Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life.

Methods/design

PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide.

Discussion

The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life.

Trial registration

ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

A comparison of three quantification methods for estimation of respiratory sinus arrhythmia

The empirical literature has shown that respiratory sinus arrhythmia is a sensitive noninvasive index of parasympathetic cardiac control. Nevertheless there has been no general agreement among investigators as to the most preferable quantification technique for assessing respiratory sinus arrhythmia, although there has been much speculation that specific estimation techniques are more or less reflective of vagal processes and could be more or less contaminated by other influences upon heart period variability unrelated to respiration. This study compared three quantification procedures for estimating respiratory sinus arrhythmia (RSA): (1) a spectral analytic technique, (2) a complex detrending approach removing periodic and aperiodic cardiac variations unrelated to respiration, and (3) a time-domain, peak-valley procedure employing inspiratory and expiratory periods as windows for determining range of cardiac-interval fluctuations associated with respiratory phase. Measures derived from these techniques were intra- and interindividually compared using three different samples of male subjects, including students, adult normotensives, and adult hypertensives. All interindividual correlations between measures yielded coefficients above .92 and the mean within-subject correlation across 42 individuals was .96, thus indicating a marked degree of comparability between measures. Additionally, given that much evidence indicates lawful within-individual relations between RSA amplitude and respiratory parameters, we employed respiratory period as an external criterion and compared intraindividual correlations between this variable and (2) and (3); results showed that (3) was significantly more highly associated with respiration than was (2), although the mean r's for the two measures did not diverge greatly (.91 vs. .84). Finally, inspection of the data and further regression analyses did not suggest that any of the RSA estimates were differentially contaminated by other components of cardiac variability. Our findings suggest that the three techniques are almost equivalent as indices of cardiac vagal tone and would appear to ease concerns about the inferiority of any of the procedures. Choice of a quantification procedure should therefore be tailored to the specific empirical needs of an investigation. The advantages and disadvantages of each method are discussed.