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Disbeschl SL, Hendry AK, Surgey A, Walker D, Goulden N, Anthony BF, Neal R, Williams NH, Hoare ZSJ, Hiscock J, Edwards RTR, Lewis R, Wilkinson C. 'ThinkCancer!' - Randomised feasibility trial of a novel practice-based early cancer diagnosis intervention. BJGP Open 2024:BJGPO.2023.0220. [PMID: 38702056 DOI: 10.3399/bjgpo.2023.0220] [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: 11/02/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety netting systems. Few interventions target whole practice teams. We developed a novel whole practice team intervention to address this. AIM To test the feasibility and acceptability of a novel, complex behavioural intervention 'ThinkCancer!' for assessment in a subsequent Phase III trial. DESIGN & SETTING Pragmatic, superiority pilot RCT with an embedded process evaluation and feasibility economic analysis in Welsh general practices. METHOD Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety netting systems were assessed. Individual practice staff completed evaluation and feedback forms, and qualitative interviews. The intervention was adapted and refined. RESULTS Trial recruitment and workshop deliveries took place between March 2020 to May 2021. Trial progression criteria for recruitment, intervention fidelity and routine data collection were met. Staff-level fidelity, retention and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety netting plans in detail. CONCLUSION 'ThinkCancer!' appears feasible and acceptable; the new iteration of the workshops was completed, and the Phase III trial has been funded to assess the effectiveness and cost effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.
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Affiliation(s)
- Stefanie Lj Disbeschl
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Annie K Hendry
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, United Kingdom
| | - Alun Surgey
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Daniel Walker
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, United Kingdom
| | - Bethany F Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Ardudwy, Normal Site, Bangor, United Kingdom
| | - Richard Neal
- Department of Health and Community Sciences, Exeter Collaboration for Academic Primary Care, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, United Kingdom
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Zoë Susannah Jane Hoare
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Y Wern, Normal Site, Holyhead Road, Bangor, United Kingdom
| | - Julia Hiscock
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Rhiannon Tudor Rt Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Ardudwy, Normal Site, Bangor, United Kingdom
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, United Kingdom
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Paton NI, Stöhr W, Arenas-Pinto A, Clarke A, Williams I, Johnson M, Orkin C, Chen F, Lee V, Winston A, Gompels M, Fox J, Sanders K, Dunn DT. Long-term efficacy and safety of a treatment strategy for HIV infection using protease inhibitor monotherapy: 8-year routine clinical care follow-up from a randomised, controlled, open-label pragmatic trial (PIVOT). EClinicalMedicine 2024; 69:102457. [PMID: 38361989 PMCID: PMC10867418 DOI: 10.1016/j.eclinm.2024.102457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
Background Treatment-simplification strategies are important tools for patient-centred management. We evaluated long-term outcomes from a PI monotherapy switch strategy. Methods Eligible participants attending 43 UK treatment centres had a viral load (VL) below 50 copies/ml for at least 24 weeks on combination ART. Participants were randomised to maintain ongoing triple therapy (OT) or switch to a strategy of physician-selected PI monotherapy (PI-mono) with prompt return to combination therapy if VL rebounded. The primary outcome, previously reported, was loss of future drug options after 3 years, defined as new intermediate/high level resistance to at least one drug to which the participant's virus was considered sensitive at trial entry. Here we report resistance and disease outcomes after further extended follow-up in routine care. The study was registered as ISRCTN04857074. Findings We randomised 587 participants to OT (291) or PI-mono (296) between Nov 4, 2008, and July 28, 2010 and followed them for a median of more than 8 years (100 months) until 2018. At the end of this follow-up time, one or more future drug options had been lost in 7 participants in the OT group and 6 in the PI-mono group; estimated cumulative risk by 8 years of 2.7% and 2.1% respectively (difference -0.6%, 95% CI -3.2% to 2.0%). Only one PI-mono participant developed resistance to the protease inhibitor they were taking (atazanavir). Serious clinical events (death, serious AIDS, and serious non-AIDS) were infrequent; reported in a total of 12 (4.1%) participants in the OT group and 23 (7.8%) in the PI-mono group (P = 0.08) over the entire follow-up period. Interpretation A strategy of PI monotherapy, with regular VL monitoring and prompt reintroduction of combination treatment following rebound, preserved future treatment options. Findings confirm the high genetic barrier to resistance of the PI drug class that makes them well suited for creative, patient-centred, treatment-simplification approaches. The possibility of a small excess risk of serious clinical events with the PI monotherapy strategy cannot be excluded. Funding The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nicholas I. Paton
- MRC Clinical Trials Unit at University College London, London, UK
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wolfgang Stöhr
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Amanda Clarke
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | | | - Chloe Orkin
- Barts and the Royal London Hospital NHS Trust, London, UK
| | | | | | | | | | - Julie Fox
- Guys and St. Thomas' Hospital, London, UK
| | - Karen Sanders
- MRC Clinical Trials Unit at University College London, London, UK
| | - David T. Dunn
- MRC Clinical Trials Unit at University College London, London, UK
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Mahar RK, McGlothlin A, Dymock M, Lee TC, Lewis RJ, Lumley T, Mora J, Price DJ, Saville BR, Snelling T, Turner R, Webb SA, Davis JS, Tong SYC, Marsh JA. A blueprint for a multi-disease, multi-domain Bayesian adaptive platform trial incorporating adult and paediatric subgroups: the Staphylococcus aureus Network Adaptive Platform trial. Trials 2023; 24:795. [PMID: 38057927 PMCID: PMC10699085 DOI: 10.1186/s13063-023-07718-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/05/2023] [Indexed: 12/08/2023] Open
Abstract
The Staphylococcus aureus Network Adaptive Platform (SNAP) trial is a multifactorial Bayesian adaptive platform trial that aims to improve the way that S. aureus bloodstream infection, a globally common and severe infectious disease, is treated. In a world first, the SNAP trial will simultaneously investigate the effects of multiple intervention modalities within multiple groups of participants with different forms of S. aureus bloodstream infection. Here, we formalise the trial structure, modelling approach, and decision rules that will be used for the SNAP trial. By summarising the statistical principles governing the design, our hope is that the SNAP trial will serve as an adaptable template that can be used to improve comparative effectiveness research efficiency in other disease areas.Trial registration NCT05137119 . Registered on 30 November 2021.
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Affiliation(s)
- Robert K Mahar
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia.
| | | | - Michael Dymock
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Canada
| | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas, USA
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Thomas Lumley
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Jocelyn Mora
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - David J Price
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Benjamin R Saville
- Berry Consultants LLC, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tom Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rebecca Turner
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Steven A Webb
- St John of God Healthcare, Perth, Western Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joshua S Davis
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, New South Wales, Australia
- Menzies School of Health Research, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
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Rodgers J, Brice S, Welsh P, Ingham B, Wilson C, Evans G, Steele K, Cropper E, Le Couteur A, Freeston M, Parr JR. A Pilot Randomised Control Trial Exploring the Feasibility and Acceptability of Delivering a Personalised Modular Psychological Intervention for Anxiety Experienced by Autistic Adults: Personalised Anxiety Treatment-Autism (PAT-A). J Autism Dev Disord 2023:10.1007/s10803-023-06112-5. [PMID: 37728782 DOI: 10.1007/s10803-023-06112-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/21/2023]
Abstract
Anxiety is commonly experienced by autistic people and impacts on quality of life and social participation. New anxiety interventions are required to effectively meet the needs of autistic people. Personalised Anxiety Treatment-Autism (PAT-A©) is a bespoke, modular approach to treating anxiety in up to 12 sessions. This study explored the feasibility and acceptability of delivering PAT-A© in the UK National Health Service (NHS). A single-blind randomised controlled trial design. Thirty-four autistic adults were recruited via clinical services and randomised to receive either PAT-A© or enhanced treatment as usual (CCSP). Outcome assessments relating to anxiety, quality of life and related constructs were completed at baseline, immediately post intervention; and at 3 and 12 months. Seventy-one percent of the PAT-A© group and 65% of the CCSP met diagnostic threshold for at least three anxiety disorders. Retention was good across both groups, with 82% (N = 14/17) completing the full course of PAT-A© and 71% (N = 12/17) attending both psychoeducational sessions in CCSP. 94% in PAT-A© and 82% in CCSP completed some follow up assessment 3 months post-intervention. Thematic analysis of interview data revealed that many participants valued the personalised approach, developed transferable skills and experienced positive changes to their anxiety. Participants were willing to be recruited and randomised, PAT-A© was feasible to deliver in the NHS and the trial methods and materials were acceptable. Our findings indicate that a fully powered clinical and cost-effectiveness trial of PAT-A© is warranted.
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Affiliation(s)
- Jacqui Rodgers
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
| | - Samuel Brice
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Patrick Welsh
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Barry Ingham
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Colin Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Gemma Evans
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Katie Steele
- School of Psychology, Newcastle University, Newcastle Upon Tyne, UK
| | - Emily Cropper
- School of Psychology, Newcastle University, Newcastle Upon Tyne, UK
| | - Ann Le Couteur
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Mark Freeston
- School of Psychology, Newcastle University, Newcastle Upon Tyne, UK
| | - Jeremy R Parr
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Walker N, Calder A, Barnes J, Laking G, Parag V, Bullen C. Effectiveness of nicotine salt vapes, cytisine, and a combination of these products, for smoking cessation in New Zealand: protocol for a three-arm, pragmatic, community-based randomised controlled trial. BMC Public Health 2023; 23:1760. [PMID: 37697327 PMCID: PMC10494376 DOI: 10.1186/s12889-023-16665-w] [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: 06/26/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Combining short-acting nicotine replacement therapy with varenicline increases smoking cessation rates compared with varenicline alone, but not all people tolerate these medications or find them helpful. We aim to investigate the therapeutic potential of an analogous combination, by evaluating the effectiveness, safety, and acceptability of combining nicotine salt e-cigarettes with cytisine, compared to nicotine salt e-cigarettes or cytisine only, on smoking abstinence at six months. METHODS A pragmatic, community-based, investigator-blinded, randomised superiority trial design will be utilised. Eligible participants will be people who smoke daily (N = 800, 90% power) from throughout New Zealand, who are: aged ≥ 18 years, motivated to quit in the next two weeks, able to provide online consent, willing to use e-cigarettes and/or cytisine, and have daily access to a mobile phone. Recruitment will utilise multi-media advertising. Participants will be randomised (3:3:2 ratio) to 12 weeks of: 1) e-cigarettes (closed pod system, 3% nicotine salt, tobacco flavour) plus cytisine; 2) e-cigarettes alone, or 3) cytisine alone. All groups will receive a six-month, text-message-based behavioural support programme. The primary outcome is self-reported, biochemically verified, continuous abstinence at six months post-quit date. Secondary outcomes, measured at quit date, then one, three, six, and 12 months post-quit date, include self-reported continuous abstinence, 7-day point prevalence abstinence, cigarettes smoked per day, withdrawal and urge to smoke, time to (re)lapse, treatment use and compliance, treatment crossover, dual-use, use of other cessation products, change in e-cigarette products, continuation of product use, acceptability, change in health state, health-related quality of life, change in body mass index, adverse events, and cost per quitter. DISCUSSION Pragmatic trials are of particular value as they reflect the 'real world' impact of interventions. The trial will provide some of the first evidence on the effectiveness of combining nicotine salt e-cigarettes with cytisine for smoking cessation, in a country with strong tobacco control policy. Findings will be incorporated into relevant systematic reviews, informing practice and policy. TRIAL REGISTRATION NCT05311085 ClinicalTrials.gov. Registered 5th April, 2022.
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Affiliation(s)
- Natalie Walker
- School of Population Health, National Institute for Health Innovation, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Amanda Calder
- School of Population Health, National Institute for Health Innovation, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Joanne Barnes
- School of Pharmacy, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - George Laking
- Department of Molecular Medicine and Pathology, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Varsha Parag
- School of Population Health, National Institute for Health Innovation, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Chris Bullen
- School of Population Health, National Institute for Health Innovation, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
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Compagnucci A, Chan MK, Saïdi Y, Cressey TR, Bamford A, Riault Y, Coelho A, Nolan A, Chalermpantmetagul S, Morkunaite G, Amuge P, Musiime V, Violari A, Cotton M, Kekitiinwa AR, Kaudha E, Groenewald M, Liberty AA, Kanjanavanit S, Volokha A, Bologna R, Pavia Ruz N, Prieto Tato L, Paioni P, Marques L, Reliquet V, Niehues T, Welch SB, Ford D, Giaquinto C, Gibb DM, Babiker A, Ramos Amador JT. Nucleoside/nucleotide reverse transcriptase inhibitor sparing regimen with once daily integrase inhibitor plus boosted darunavir is non-inferior to standard of care in virologically-suppressed children and adolescents living with HIV - Week 48 results of the randomised SMILE Penta-17-ANRS 152 clinical trial. EClinicalMedicine 2023; 60:102025. [PMID: 37304494 PMCID: PMC10251070 DOI: 10.1016/j.eclinm.2023.102025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Background Integrase inhibitor (INSTI) with boosted darunavir (DRV/r), a regimen with a high-resistance barrier, avoiding NRTI toxicities, might be a switching option in children living with HIV (CLWHIV). Methods SMILE is a randomised non-inferiority trial evaluating safety and antiviral efficacy of once-daily INSTI + DRV/r vs. continuing on current standard-of-care (SOC) triple ART (2NRTI + boosted PI/NNRTI) in virologically-suppressed CLWHIV aged 6-18 years. The primary outcome is the proportion with confirmed HIV-RNA ≥50 copies/mL by week 48, estimated by Kaplan-Meier method. Non-inferiority margin was 10%. Registration number for SMILE are: ISRCTN11193709, NCT #: NCT02383108. Findings Between 10th June 2016 and 30th August 2019, 318 participants were enrolled from Africa 53%, Europe 24%, Thailand 15% and Latin America 8%, 158 INSTI + DRV/r [153 Dolutegravir (DTG); 5 Elvitegravir (EVG)], 160 SOC. Median (range) age was 14.7 years (7.6-18.0); CD4 count 782 cells/mm3 (227-1647); 61% female. Median follow-up was 64.3 weeks with no loss to follow-up. By 48 weeks, 8 INSTI + DRV/r vs. 12 SOC had confirmed HIV-RNA ≥50 copies/mL; difference (INSTI + DRV/r-SOC) -2.5% (95% CI: -7.6, 2.5%), showing non-inferiority. No major PI or INSTI resistance mutations were observed. There were no differences in safety between arms. By week 48, difference (INSTI + DRV/r-SOC) in mean CD4 count change from baseline was -48.3 cells/mm3 (95% CI: -93.4, -3.2; p = 0.036). Difference (INSTI + DRV/r-SOC) in mean HDL change from baseline was -4.1 mg/dL (95% CI: -6.7, -1.4; p = 0.003). Weight and Body Mass Index (BMI) increased more in INSTI + DRV/r than SOC [difference: 1.97 kg (95% CI: 1.1, 2.9; p < 0.001), 0.66 kg/m2 (95% CI: 0.3, 1.0; p < 0.001)]. Interpretation In virologically-suppressed children, switching to INSTI + DRV/r was non-inferior virologically, with similar safety profile, to continuing SOC. Small but significant differences in CD4, HDL-cholesterol, weight and BMI were observed between INSTI + DRV/r vs. SOC although clinical relevance needs further investigation. SMILE data corroborate adult findings and provide evidence for this NRTI-sparing regimen for children and adolescents. Funding Fondazione Penta Onlus, Gilead, Janssen, INSERM/ANRS and UK MRC. ViiV-Healthcare provided Dolutegravir.
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Affiliation(s)
| | | | - Yacine Saïdi
- INSERM SC10-US19, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France
| | - Tim R. Cressey
- AMS-CMU & IRD Research Collaboration, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Thailand
| | - Alasdair Bamford
- MRC Clinical Trials Unit at UCL, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Yoann Riault
- INSERM SC10-US19, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France
| | - Alexandra Coelho
- INSERM SC10-US19, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France
| | | | - Suwalai Chalermpantmetagul
- AMS-CMU & IRD Research Collaboration, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Thailand
| | | | - Pauline Amuge
- Baylor College of Medicine Children's Foundation, Kampala, Uganda
| | - Victor Musiime
- Joint Clinical Research Centre, Lubowa, Kampala, Uganda
- Makerere University, Department of Paediatrics and Child Health, Kampala, Uganda
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Cotton
- FAMCRU, Department of Paediatrics & Child Health, Family Center for Research with Ubuntu, Stellenbosch University, South Africa
| | | | | | - Marisa Groenewald
- FAMCRU, Department of Paediatrics & Child Health, Family Center for Research with Ubuntu, Stellenbosch University, South Africa
| | - Afaaf A. Liberty
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Alla Volokha
- Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | | | - Noris Pavia Ruz
- Clínica para niños con VIH, UNAM/HGM; Unidad de Investigación en Medicina Experimental, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | | | - Paolo Paioni
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Laura Marques
- Centro Materno-Infantil do Norte, CHU Porto, Porto, Portugal
| | - Véronique Reliquet
- Infectious Diseases Department, CHU Hôtel Dieu and INSERM UIC 1413, Nantes University, Nantes, France
| | - Tim Niehues
- Centre for Child Health and Adolescence, Helios Klinikum Krefeld, Academic Hospital, RWTH Aachen, Krefeld, Germany
| | - Steven B. Welch
- Department of Paediatrics, Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | | | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | | | | | - Jose Tomas Ramos Amador
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC); Fundación para la Investigación Biomédica HCSC; Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
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Hernández-Bernal F, Ricardo-Cobas MC, Martín-Bauta Y, Rodríguez-Martínez E, Urrutia-Pérez K, Urrutia-Pérez K, Quintana-Guerra J, Navarro-Rodríguez Z, Piñera-Martínez M, Rodríguez-Reinoso JL, Chávez-Chong CO, Baladrón-Castrillo I, Melo-Suárez G, Batista-Izquierdo A, Pupo-Micó A, Mora-Betancourt R, Bizet-Almeida J, Martínez-Rodríguez MC, Lobaina-Lambert L, Velázquez-Pérez VM, Soler-Díaz J, Laurencio-Vallina S, Meriño-Hechavarría T, Carmenaty-Campos N, Rodríguez-Montero E, Limonta-Fernández M, Alonso-Valdés M, Hernández-Rodríguez R, Pimentel-Vázquez E, Catasús-Álvarez KM, Cabrera-Núñez MV, Ayala-Ávila M, Muzio-González VL. A phase 3, randomised, double-blind, placebo-controlled clinical trial evaluation of the efficacy and safety of a SARS-CoV-2 recombinant spike RBD protein vaccine in adults (ABDALA-3 study). Lancet Reg Health Am 2023; 21:100497. [PMID: 37192953 PMCID: PMC10160525 DOI: 10.1016/j.lana.2023.100497] [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] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/28/2023] [Accepted: 04/14/2023] [Indexed: 05/18/2023]
Abstract
Background The pandemic of COVID-19 raised the urgent need for safe and efficacious vaccines against SARS-CoV-2. We evaluated the efficacy and safety of a new SARS-CoV-2 virus receptor-binding domain (RBD) vaccine. Methods A phase 3, multicentre, randomised, double-blind, placebo-controlled trial was carried out at 18 clinical sites in three provinces of the south-eastern region of Cuba. Subjects (healthy or those with controlled chronic diseases) aged between 19 and 80 years, who gave written informed consent were eligible. Subjects were randomly assigned (1:1, in blocks) to two groups: placebo, and 50 μg RBD vaccine (Abdala). The product was administered intramuscularly, 0.5 mL in the deltoid region, in a three-dose immunization schedule at 0-14-28 days. The organoleptic characteristics and presentations of the vaccine and placebo were identical. All participants (subjects, clinical researchers, statisticians, laboratory technicians, and monitors) remained blinded during the study period. The main endpoint was to evaluate the efficacy of the Abdala vaccine in the prevention of symptomatic COVID-19. The trial is registered with the Cuban Public Registry of Clinical Trials, RPCEC00000359. Findings Between March 22 to April 03, 2021, 48,290 subjects were included (24,144 and 24,146 in the placebo and Abdala groups, respectively) in the context of predominant D614G variant circulation. The evaluation of the main efficacy outcomes occurred during May-June 2021, starting at May 3rd, in the context of high circulation of mutant viruses, predominantly VOC Beta. The incidence of adverse reactions for individuals in the placebo and Abdala vaccine groups were 1227/24,144 (5.1%) and 1621/24,146 (6.7%), respectively. Adverse reactions were mostly mild, and from the injection site, which resolved in the first 24-48 h. No severe adverse events with demonstrated cause-effect relationship attributable to the vaccine were reported. Symptomatic COVID-19 disease was confirmed in 142 participants in the placebo group (78.44 incidence per 1000 person-years, 95% confidence interval [CI], 66.07-92.46) and in 11 participants in Abdala vaccine group (6.05 incidence per 1000 person years; 95% CI 3.02-10.82). The Abdala vaccine efficacy against symptomatic COVID-19 was 92.28% (95% CI 85.74-95.82). Moderate/serious forms of COVID-19 occurred in 30 participants (28 in the placebo group and only 2 in the Abdala vaccine group) for a vaccine efficacy of 92.88% (95% CI 70.12-98.31). There were five critical patients (of which four died), all in the placebo group. Interpretation The Abdala vaccine was safe, well tolerated, and highly effective, fulfilling the WHO target product profile for COVID-19 vaccines. Those results, along with its immunization schedule and the advantage of easy storage and handling conditions at 2-8 °C, make this vaccine an option for the use in immunization strategies as a key tool for the control of the pandemic. Funding Centre for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Maria V. Cabrera-Núñez
- Virology Laboratory of the Center for Hygiene, Epidemiology and Microbiology, Santiago de Cuba, Cuba
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Slater S, Bryant A, Chen HC, Begum R, Rana I, Aresu M, Peckitt C, Zhitkov O, Lazaro-Alcausi R, Borja V, Powell R, Lowery D, Hubank M, Rich T, Anandappa G, Chau I, Starling N, Cunningham D. ctDNA guided adjuvant chemotherapy versus standard of care adjuvant chemotherapy after curative surgery in patients with high risk stage II or stage III colorectal cancer: a multi-centre, prospective, randomised control trial (TRACC Part C). BMC Cancer 2023; 23:257. [PMID: 36941575 PMCID: PMC10026439 DOI: 10.1186/s12885-023-10699-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/02/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Circulating tumour DNA (ctDNA) to detect minimal residual disease (MRD) is emerging as a biomarker to predict recurrence in patients with curatively treated early stage colorectal cancer (CRC). ctDNA risk stratifies patients to guide adjuvant treatment decisions. We are conducting the UK's first multi-centre, prospective, randomised study to determine whether a de-escalation strategy using ctDNA to guide adjuvant chemotherapy (ACT) decisions is non-inferior to standard of care (SOC) chemotherapy, as measured by 3-year disease free survival (DFS) in patients with resected CRC with no evidence of MRD (ctDNA negative post-operatively). In doing so we may be able to spare patients unnecessary chemotherapy and associated toxicity and achieve significant cost savings for the National Health Service (NHS). METHODS We are recruiting patients with fully resected high risk stage II and stage III CRC who are being considered for ACT into the study which uses results from a plasma-only ctDNA assay to guide treatment decisions. Eligible patients are randomised 1:1 to receive ctDNA-guided chemotherapy versus SOC chemotherapy. The primary endpoint is the difference in DFS at 3 years between the trial arms. Secondary endpoints include the proportion of patients in the ctDNA-guided arm who are ctDNA negative post-operatively and receive de-escalated ACT compared to the standard arm, the difference in overall survival (OS), neurotoxicity and quality of life between the arms, and the cost-effectiveness of ctDNA-guided therapy compared to SOC treatment. We hypothesise that using a ctDNA-guided approach to ACT decisions is non-inferior to SOC. Target accrual is 1621 patients over 4 years, which will provide a power of 80% with an alpha of 0.1 to demonstrate non-inferiority with a margin of 1.25 in survival of the ctDNA-guided approach compared to SOC. We anticipate approximately 50 UK centres will participate. The study opened with the Guardant Reveal plasma-only ctDNA assay in August 2022. DISCUSSION The trial will determine whether ctDNA guided ACT is non-inferior to SOC ACT in patients with fully resected high risk stage II and stage III resected CRC, with the potential to significantly reduce unnecessary ACT and the toxicity associated with it. TRIAL REGISTRATION NCT04050345.
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Affiliation(s)
| | | | | | - Ruwaida Begum
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Isma Rana
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Maria Aresu
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Clare Peckitt
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Oleg Zhitkov
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | | | - Rachel Powell
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - David Lowery
- Biomedical Research Centre at the Royal Marsden and the Institute of Cancer Research, London, UK
| | - Michael Hubank
- Centre for Molecular Pathology at the The Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK
| | | | | | - Ian Chau
- Royal Marsden Hospital NHS Foundation Trust, London, UK
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Agarwal N, Kumbhat P, Agarwal S. Subcutaneous Randomized Nasolabial Flap: Our Experience. Indian J Otolaryngol Head Neck Surg 2022; 74:2236-2240. [PMID: 36452821 PMCID: PMC9701957 DOI: 10.1007/s12070-020-02097-0] [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] [Received: 08/05/2020] [Accepted: 08/24/2020] [Indexed: 11/29/2022] Open
Abstract
Nasolabial flaps are one of the oldest methods of reconstruction. This study aims to observe the viability of a random-pattern subcutaneous nasolabial flap. Inpatients of carcinoma of oral cavity and nose undergoing excision with primary reconstruction from January 2014 to December 2019 were observed and followed-up. Their data including site of primary and post-operative complication was recorded. A total of 38 patients underwent reconstruction using nasolabial flap. Most cases were of buccal mucosa carcinoma (68.4%). Facial vessels were ligated in all except 7 cases and, only 1 (2.6%) showed total, and 3 (7.9%) showed partial flap necrosis. A subcutaneous nasolabial flap is simple, viable and easy to harvest. It is a random-pattern flap therefore; facial vessel preservation may not be a compulsion. Flap raised subcutaneously is thinner and thus inset is easy and bulk associated discomfort is avoided.
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Affiliation(s)
- Navneet Agarwal
- Department of Otorhinolaryngology and Head and Neck Surgery, Dr. S.N. Medical College and M.D.M. Hospital, Jodhpur, Rajasthan 342003 India
| | - Payal Kumbhat
- Department of Otorhinolaryngology and Head and Neck Surgery, Dr. S.N. Medical College and M.D.M. Hospital, Jodhpur, Rajasthan 342003 India
| | - Sukriti Agarwal
- Dr. S.N. Medical College and M.D.M. Hospital, Jodhpur, Rajasthan 342003 India
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Fennell DA, Porter C, Lester J, Danson S, Blackhall F, Nicolson M, Nixon L, Gardner G, White A, Griffiths G, Casbard A. Olaparib maintenance versus placebo monotherapy in patients with advanced non-small cell lung cancer (PIN): A multicentre, randomised, controlled, phase 2 trial. EClinicalMedicine 2022; 52:101595. [PMID: 35990583 PMCID: PMC9386392 DOI: 10.1016/j.eclinm.2022.101595] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 10/27/2022] Open
Abstract
Background Impaired double strand DNA repair by homologous repair deficiency (HRD) leads to sensitivity to poly ADP ribose polymerase (PARP) inhibition. Poly-ADP ribose polymerase (PARP) inhibitors target HRD to induce synthetic lethality and are used routinely in the treatment of BRCA1 mutated ovarian cancer in the platinum-sensitive maintenance setting. A subset of non-small cell lung cancers (NSCLCs) harbour impaired DNA double strand break repair. We therefore hypothesised that patients with metastatic non-small cell lung cancer exhibiting partial responses to platinum doublet-based chemotherapy, might enrich for impaired HRD, rendering these tumours more sensitive to inhibition of PARP inhibition by olaparib. Methods The Olaparib Maintenance versus Placebo Monotherapy in Patients with Advanced Non-Small Cell Lung Cancer trial (PIN) was a multicentre double-blind placebo controlled randomised phase II screening trial. This study was conducted at 23 investigative hospital sites in the UK. Patients had advanced (stage IIIB/IV) squamous (Sq) or non-squamous (NSq) NSCLC, and had to be chemo-naive, European Cooperative Oncology Group (ECOG) performance status 0-1. Prior immunotherapy with a PD1 or PDL1 inhibitor was allowed. Patients could be registered for PIN prior to (stage 1), or after (stage 2) initiation of induction chemotherapy. If any tumour shrinkage was observed (any shrinkage of RECIST target lesions), following a minimum of 3 cycles of platinum doublet chemotherapy, patients were randomised 1:1 using a centralised online system, to either olaparib (300 mg twice daily by mouth in 21-day cycles) or placebo, which was continued until disease progression, or unacceptable toxicity. Intention to treat (ITT) analyses of the primary endpoint included all randomised participants. Per protocol (PP) safety analysis included all participants who received at least one dose of study drug. Primary endpoint was progression-free survival (PFS), with a one-sided p-value of 0.2 to demonstrate statistical significance. Hazard ratios (HR) for PFS were both unadjusted and adjusted for the randomisation balancing factors (smoking status and histology). The trial was registered with ClinicalTrials.gov (NCT01788332) and EudraCT (2012-003383-51). Findings A total of 940 patients were assessed for stage 1 eligibility of whom 263 were registered between Feb 24, 2014 and Nov 7, 2017. 194 patients were excluded prior to stage 2 (no tumour shrinkage or unevaluable) and 70 were randomised; 32 (46%) to Olaparib and 38 (54%) to placebo. 4% (3/70) of patients randomised had a CR and 96% (67/70) had a PR (or other evidence of tumour response/mixed stable) during induction therapy. A total of 36 patients were registered in stage 2 only, i.e., post induction therapy. Intention to treat (ITT) unadjusted analysis showed a PFS hazard ratio (HR) of 0.83 (one-sided 80% CI upper limit 1.03, one-sided unadjusted log rank test p-value=0.23). ITT Cox-adjusted model showed a HR 0.73 (one-sided 80% CI upper limit 0.91, one sided p-value 0.11). Adverse events were reported in 31/32 subjects (97%) in the olaparib arm and 38/38 (100%) in the placebo group. The most commonly reported adverse events in the olaparib group were fatigue (20/31; 65%), nausea (17/31; 55%), anaemia (15/31; 48%) and dyspnea (13/31; 42%). In the placebo group the most common adverse events were fatigue (25/38; 66%), coughing (22/38; 58%), dyspnea (15/38; 39%) and nausea (11/38; 29%). There were no treatment-related deaths. Interpretation PFS was longer in the olaparib arm, but this did not reach statistical significance. When the PFS HR was adjusted for smoking status and histology, a significant difference at the one-sided 0.2 level was observed, suggesting that tumour control may be achieved for chemosensitive NSCLC treated with PARP monotherapy. We speculate that this signal may be driven by a molecular subgroup harbouring HRD. Funding This study was funded between AstraZeneca CRUK, National Cancer Research Institute, and Cancer Research UK Feasibility Study Committee.
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Affiliation(s)
- Dean A. Fennell
- University of Leicester & University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | | | | | | | - Lisette Nixon
- Centre for Trials Research, Cardiff University, South Wales, UK
| | | | - Ann White
- Centre for Trials Research, Cardiff University, South Wales, UK
| | | | - Angela Casbard
- Centre for Trials Research, Cardiff University, South Wales, UK
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Human MJ, Tshifularo N, Mabitsela M. Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial. Pediatr Surg Int 2022; 38:1291-1296. [PMID: 35771234 PMCID: PMC9355919 DOI: 10.1007/s00383-022-05155-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE This was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain. METHODS Patients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019-2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the "drain" (D) and "no drain" (ND) groups. RESULTS Thirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the "D" group was 18% and 35% in the "ND" group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups. CONCLUSION From our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications. TRIAL REGISTRATION NUMBER SMUREC/M/15/2019: PG.
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Affiliation(s)
- M J Human
- Department of Paediatric Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Molotlegi Road, Ga-Rankuwa, Pretoria, 0208, South Africa.
| | - N Tshifularo
- Department of Paediatric Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Molotlegi Road, Ga-Rankuwa, Pretoria, 0208, South Africa
| | - M Mabitsela
- Department of Paediatric Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Molotlegi Road, Ga-Rankuwa, Pretoria, 0208, South Africa
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Espenel S, Chargari C, Blanchard P, Bockel S, Morel D, Rivera S, Levy A, Deutsch E. Practice changing data and emerging concepts from recent radiation therapy randomised clinical trials. Eur J Cancer 2022; 171:242-258. [PMID: 35779346 DOI: 10.1016/j.ejca.2022.04.038] [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] [Received: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Oncology treatments are constantly and rapidly evolving. We aimed at highlighting the latest radiation therapy practice changing trials and emerging concepts, through an overview of recent randomised clinical trials (RCTs). MATERIALS AND METHODS Requests were performed in the Medline database to identify all publications reporting radiation therapy RCTs from 2018 to 2021. RESULTS Recent RCTs sustained the role of newer combinatorial strategies through radioimmunotherapy for early stage or metastatic lung cancer, newer pro-apoptotic agents (e.g. debio 1143 in locoregionally advanced head and neck squamous cell carcinoma) or nanoparticles (e.g. NBTXR3 in locally advanced soft-tissue sarcoma). High-tech radiotherapy allows intensifying treatments and gaining ground in some indications through the development of stereotactic body radiotherapy for example. First randomised evidence on personalised radiation therapy through imaging-based (18FDG positron emission tomography-computed tomography for lung cancer or early stage unfavourable Hodgkin lymphoma, PMSA positron emission tomography-computed tomography or magnetic resonance imaging for high-risk prostate cancer) or biological biomarkers (PSA for prostate cancer, HPV for head and neck cancer, etc) were conducted to more tailored treatments, with more favourable outcomes. Patients' quality of life and satisfaction appeared to be increasing aims. RCTs have validated (ultra)hypofractionated schemes in many indications as for breast, prostate or rectal cancer, resulting in equivalent outcomes and toxicities, more convenient for patients and favouring shared decision making. CONCLUSION Radiation therapy is a dynamic field of research, and many RCTs have greatly impacted therapeutic standards over the last years. Investments in radiotherapy research should facilitate the transfer of innovation to clinic.
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Affiliation(s)
- Sophie Espenel
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France.
| | - Cyrus Chargari
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Institut de Recherche Biomédicale des Armées, F-91220, Brétigny sur Orge, France.
| | - Pierre Blanchard
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Faculté de Médecine, F-94270, Le Kremlin Bicêtre, France; Oncostat, Inserm U-1018, F-94805, Villejuif, France.
| | - Sophie Bockel
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France.
| | - Daphne Morel
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France.
| | - Sofia Rivera
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Inserm U-1030, Laboratoire de Radiothérapie Moléculaire et d'Innovation Thérapeutique, F-94805, Villejuif, France.
| | - Antonin Levy
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Faculté de Médecine, F-94270, Le Kremlin Bicêtre, France; Université Paris-Saclay, Inserm U-1030, Laboratoire de Radiothérapie Moléculaire et d'Innovation Thérapeutique, F-94805, Villejuif, France.
| | - Eric Deutsch
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Faculté de Médecine, F-94270, Le Kremlin Bicêtre, France; Université Paris-Saclay, Inserm U-1030, Laboratoire de Radiothérapie Moléculaire et d'Innovation Thérapeutique, F-94805, Villejuif, France.
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Fennell DA, Porter C, Lester J, Danson S, Taylor P, Sheaff M, Rudd RM, Gaba A, Busacca S, Nixon L, Gardner G, Darlison L, Poile C, Richards C, Jordan PW, Griffiths G, Casbard A. Active symptom control with or without oral vinorelbine in patients with relapsed malignant pleural mesothelioma (VIM): A randomised, phase 2 trial. EClinicalMedicine 2022; 48:101432. [PMID: 35706488 PMCID: PMC9124711 DOI: 10.1016/j.eclinm.2022.101432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/03/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background Currently, there is no US Food and Drug Administration approved therapy for patients with pleural mesothelioma who have relapsed following platinum-doublet based chemotherapy. Vinorelbine has demonstrated useful clinical activity in mesothelioma, however its efficacy has not been formally evaluated in a randomised setting. BRCA1 expression is required for vinorelbine induced apoptosis in preclinical models. Loss of expression may therefore correlate with vinorelbine resistance. Methods In this randomised, phase 2 trial, patients were eligible if they met the following criteria: age ≥ 18 years, Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1, histologically confirmed pleural mesothelioma, post platinum-based chemotherapy, and radiological evidence of disease progression. Consented patients were randomised 2:1 to either active symptom control with oral vinorelbine versus active symptom control (ASC) every 3 weeks until disease progression, unacceptable toxicity or withdrawal at an initial dose of 60 mg/m2 increasing to 80 mg/m2 post-cycle 1. Randomisation was stratified by histological subtype, white cell count, gender, ECOG performance status and best response during first-line therapy. The study was open label. The primary endpoint was progression-free survival (PFS), measured from randomisation to time of event (or censoring). Analyses were carried out according to intention-to-treat (ITT) principles. Recruitment and trial follow-up are complete. This trial is registered with ClinicalTrials.gov, number NCT02139904. Findings Between June 1, 2016 and Oct 31, 2018, we performed a randomised phase 2 trial in 14 hospitals in the United Kingdom. 225 patients were screened for eligibility, of whom 154 were randomly assigned to receive either ASC + vinorelbine (n = 98) or ASC (n = 56). PFS was significantly longer for ASC+vinorelbine compared with ASC alone; 4.2 months (interquartile range (IQR) 2.2-8.0) versus 2.8 months (IQR 1.4-4.1) for ASC, giving an unadjusted hazard ratio (HR) of 0·60 (80% CI upper limit 0.7, one-sided unadjusted log rank test p = 0.002); adjusted HR 0.6 (80% CI upper limit 0.7, one-sided adjusted log rank test p < 0.001). BRCA1 did not predict resistance to ASC+vinorelbine. Neutropenia was the most common grades 3, 4 adverse events in the ASC +vinorelbine arm. Interpretation Vinorelbine plus ASC confers clinical benefit to patients with relapsed pleural mesothelioma who have progressed following platinum-based doublet chemotherapy. Funding This study was funded by Cancer Research UK (grant CRUK A15569).
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Affiliation(s)
- Dean A. Fennell
- Mesothelioma Research Programme, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester LE2 7LX, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Sarah Danson
- Sheffield ECMC, University of Sheffield and Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Paul Taylor
- Department of Medical Oncology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | | | | | - Aarti Gaba
- Mesothelioma Research Programme, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester LE2 7LX, UK
| | - Sara Busacca
- Mesothelioma Research Programme, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester LE2 7LX, UK
| | - Lisette Nixon
- Centre for Trials Research, Cardiff University, Wales, UK
| | | | - Liz Darlison
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Charlotte Poile
- Mesothelioma Research Programme, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester LE2 7LX, UK
| | - Cathy Richards
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Peter-Wells Jordan
- Mesothelioma Research Programme, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester LE2 7LX, UK
| | - Gareth Griffiths
- CRUK Southampton Clinical Trials Unit, University of, Southampton, Southampton, UK
| | - Angela Casbard
- Centre for Trials Research, Cardiff University, Wales, UK
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Katsanos K, Spiliopoulos S, Teichgräber U, Kitrou P, Del Giudice C, Björkman P, Bisdas T, de Boer S, Krokidis M, Karnabatidis D. Editor's Choice - Risk of Major Amputation Following Application of Paclitaxel Coated Balloons in the Lower Limb Arteries: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2022; 63:60-71. [PMID: 34326002 DOI: 10.1016/j.ejvs.2021.05.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/15/2021] [Accepted: 05/23/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE There have been concerns about the long term safety of paclitaxel coated devices in the lower limbs. A formal systematic review and meta-analysis of randomised controlled trials (RCTs) was performed to examine the long term risk of major amputation using paclitaxel coated balloons in peripheral arterial disease (PAD). METHOD This systematic review was registered with PROSPERO (ID 227761). A broad bibliographic search was performed for RCTs investigating paclitaxel coated balloons in the peripheral arteries (femoropopliteal and infrapopliteal) for treatment of intermittent claudication or critical limb ischaemia (CLI). The literature search was last updated on 20 February 2021 without any restrictions on publication language, date, or status. Major amputations were analysed with time to event methods employing one and two stage models. Sensitivity and subgroup analyses, combinatorial meta-analysis, and a multivariable dose response meta-analysis to examine presence of a biological gradient were also performed. RESULTS In all, 21 RCTs with 3 760 lower limbs were analysed (52% intermittent claudication and 48% CLI; median follow up two years). There were 87 major amputations of 2 216 limbs in the paclitaxel arms (4.0% crude risk) compared with 41 major amputations in 1 544 limbs in the control arms (2.7% crude risk). The risk of major amputation was significantly higher for paclitaxel coated balloons with a hazard ratio (HR) of 1.66 (95% CI 1.14 - 2.42; p = .008, one stage stratified Cox model). The prediction interval was 95% CI 1.10 - 2.46 (two stage model). The observed amputation risk was consistent for both femoropopliteal (p = .055) and infrapopliteal (p = .055) vessels. Number needed to harm was 35 for CLI. There was good evidence of a significant non-linear dose response relationship with accelerated risk per cumulative paclitaxel dose (chi square model p = .007). There was no evidence of publication bias (p = .80) and no significant statistical heterogeneity between studies (I2 = 0%, p = .77). Results were stable across sensitivity analyses (different models and subgroups based on anatomy and clinical indication and excluding unpublished trials). There were no influential single trials. Level of certainty in evidence was downrated from high to moderate because of sparse events in some studies. CONCLUSION There appears to be heightened risk of major amputation after use of paclitaxel coated balloons in the peripheral arteries. Further investigations are warranted urgently.
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Affiliation(s)
| | | | - Ulf Teichgräber
- University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | | | | | | | | | - Sanne de Boer
- Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Miltiadis Krokidis
- Areteion Hospital, National and Kapodistrian University of Athens, Greece; Inselspital Bern University Hospital, University of Bern, Switzerland
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15
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Brauer SG, Kuys SS, Paratz JD, Ada L. High-intensity treadmill training and self-management for stroke patients undergoing rehabilitation: a feasibility study. Pilot Feasibility Stud 2021; 7:215. [PMID: 34876235 PMCID: PMC8650326 DOI: 10.1186/s40814-021-00941-w] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physical activity undertaken by stroke survivors is generally low. This trial investigated the feasibility of delivering a high-intensity treadmill and self-management program to people with stroke undergoing inpatient rehabilitation and determine whether physical activity, walking ability and cardiorespiratory fitness could be increased. METHOD A phase I, single-group, pre-post intervention study was conducted with stroke survivors undergoing inpatient rehabilitation who could walk. Participants undertook a high-intensity treadmill and self-management program for up to 30 min, three times a week for 8 weeks under the supervision of their usual physiotherapist. Feasibility was determined by examining compliance, satisfaction and adverse events. Clinical outcomes were amount of physical activity, walking ability, and cardiorespiratory fitness collected pre-training (week 0), post-training (week 8), and at follow-up (week 26). RESULTS Forty stroke survivors participated, completing 10 (SD 6) sessions, 94% at the specified training intensity, with high satisfaction and no adverse events related to the intervention. At week 8, participants completed 2749 steps/day (95% CI 933 to 4564) more physical activity than at week 0. Walking distance increased by 110 m (95% CI 23 to 196), walking speed by 0.24 m/s (95% CI 0.05 to 0.42), and VO2 peak by 0.29 ml/kg/min (95% CI 0.03 to 0.56). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained. CONCLUSIONS A high-intensity treadmill training program embedded within a self-management approach during inpatient rehabilitation appears feasible and potentially may offer sustained improvements in physical activity, walking ability, fitness, and quality of life. A randomised trial is warranted. TRIAL REGISTRATION This feasibility study was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000764730 ).
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Affiliation(s)
- Sandra G Brauer
- Discipline of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia.
| | - Suzanne S Kuys
- School of Physiotherapy, Australian Catholic University, Banyo, Queensland, Australia
| | - Jennifer D Paratz
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia.,School of Allied Health Sciences, Griffith University, Southport, Queensland, Australia
| | - Louise Ada
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
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16
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Murphy D, Ster IC, Kaski JC, Anderson L, Banerjee D. The LIFT trial: study protocol for a double-blind, randomised, placebo-controlled trial of K +-binder Lokelma for maximisation of RAAS inhibition in CKD patients with heart failure. BMC Nephrol 2021; 22:254. [PMID: 34229607 PMCID: PMC8258742 DOI: 10.1186/s12882-021-02439-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 11/18/2020] [Accepted: 06/10/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND CKD is common in heart failure (HF) and associated with morbidity and mortality, yet life-prolonging medications such as renin-angiotensin-aldosterone inhibitors (RAASi) are underused due to risk of hyperkalaemia. Sodium zirconium cyclosilicate (SZC) is a potassium-binding medication that has been shown to reduce incidence of hyperkalaemia in CKD, non-CKD, and HF populations, which we propose will support maximisation of RAASi therapy. METHODS We propose a 1:1 randomised, double-blind, placebo-controlled trial in which participants will receive either SZC or placebo. We will up-titrate participants' RAASi therapy while monitoring their serum potassium levels and adjusting their SZC dose if necessary. Participants with CKD and HF will be recruited from CKD and HF clinics at St George's Hospital. The total study period will be 18 months; 130 participants will be enrolled for approximately two months each following screening. Our primary outcome will be the proportion of participants who achieve maximum RAASi dose while maintaining normokalaemia. Secondary outcomes include participants reaching maximum RAASi dose without severe hyperkalaemia; time from randomisation to hyperkalaemia; time from randomisation to severe hyperkalaemia; number of RAASi dose escalations per participant; final doses of RAASi therapy; changes in quality of life score, eGFR, ACR, serum sodium, troponin T; number and duration of hospital admissions; and within-participant change in serum potassium compared to baseline. DISCUSSION This trial will be the first to examine the use of SZC for the maximisation of RAASi dosing in patients with advanced CKD and HF. We will assess the impact of achieving target RAASi dosing on hospital admission rates and duration of stay, with the hope that optimum RAASi treatment will translate into reduced morbidity and improved QoL. If clinical benefit is demonstrated, we hope that the joint multidisciplinary CKD-HF approach will be expanded. TRIAL REGISTRATION EudraCT number 2020-002946-18. Registered on 08 June 2020. Online record pending.
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Affiliation(s)
- Daniel Murphy
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Irina Chis Ster
- St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Juan-Carlos Kaski
- St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Lisa Anderson
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Debasish Banerjee
- St George's University Hospitals NHS Foundation Trust, London, UK.
- St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
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17
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Clement PMJ, Dirven L, Eoli M, Sepulveda-Sanchez JM, Walenkamp AME, Frenel JS, Franceschi E, Weller M, Chinot O, De Vos FYFL, Whenham N, Sanghera P, Looman J, Kundu MG, Peter de Geus J, Nuyens S, Spruyt M, Gorlia T, Coens C, Golfinopoulos V, Reijneveld JC, van den Bent MJ. Impact of depatuxizumab mafodotin on health-related quality of life and neurological functioning in the phase II EORTC 1410/INTELLANCE 2 trial for EGFR-amplified recurrent glioblastoma. Eur J Cancer 2021; 147:1-12. [PMID: 33601293 DOI: 10.1016/j.ejca.2021.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND In the EORTC 1410/INTELLANCE 2 randomised, phase II study (NCT02343406), with the antibody-drug conjugate depatuxizumab mafodotin (Depatux-M, ABT-414) in patients with recurrent EGFR-amplified glioblastoma, the primary end-point (overall survival) was not met, and the drug had ocular dose-limiting toxicity. This study reports results from the prespecified health-related quality of life (HRQoL) and neurological deterioration-free survival (NDFS) exploratory analysis. PATIENTS AND METHODS Patients (n = 260) were randomised 1:1:1 to receive either Depatux-M 1.25 mg/kg or 1.0 mg/kg intravenously every 2 weeks with oral temozolomide (TMZ) 150 mg/m2, Depatux-M alone, or TMZ or oral lomustine (CCNU) 110 mg/m2 (TMZ/CCNU). HRQoL outcomes were recorded using the EORTC core Quality of Life QLQ-C30, and brain cancer-specific QLQ-BN20 questionnaires. Questionnaires were completed at baseline, weeks 8 and 16, and month 6, and changes from baseline to each time point were calculated. NDFS was defined as time to first deterioration in World Health Organisation performance status. RESULTS Compliance with HRQoL was 88.1% at baseline and decreased to 37.9% at month 6. Differences from baseline between Depatux-M arms and TMZ/CCNU in global health/QoL status throughout treatment did not reach clinical relevance (≥10 points). Self-reported visual disorders deteriorated to a clinically relevant extent with Depatux-M arms versus TMZ/CCNU at all timepoints (mean differences range: 24.6-35.1 points). Changes from baseline for other HRQoL scales and NDFS were generally similar between treatment arms. CONCLUSIONS Depatux-M had no impact on HRQoL and NDFS in patients with EGFR-amplified recurrent glioblastoma, except for more visual disorders, an expected side-effect of the study drug. CLINICAL TRIAL REGISTRATION NCT02343406.
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Affiliation(s)
- Paul M J Clement
- Department of Oncology, Leuven Cancer Institute, KU Leuven, Leuven, Belgium.
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.
| | - Marica Eoli
- Unit of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | | | - Annemiek M E Walenkamp
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
| | - Jean S Frenel
- Medical Oncology, Institut de Cancerologie de L'Ouest, Saint-Herblain, France.
| | - Enrico Franceschi
- Medical Oncology Department, AUSL / IRCCS Institute of Neurological Sciences, Bologna, Italy.
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland.
| | - Olivier Chinot
- Aix-Marseille Univ, APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service de Neuro-Oncologie, Marseille, France.
| | - Filip Y F L De Vos
- Department of Medical Oncology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands.
| | | | - Paul Sanghera
- University Hospitals Birmingham, Edgbaston, Birmingham, United Kingdom.
| | - Jim Looman
- Pharmaceutical Development, AbbVie, Hoofddorp, the Netherlands.
| | | | | | | | | | | | | | | | - Jaap C Reijneveld
- Brain Tumor Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands.
| | - Martin J van den Bent
- Department of Neurology, Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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18
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Larsson M, Nordeman L, Holmgren K, Grimby-Ekman A, Hensing G, Björkelund C, Bergman S, Ekhammar A, Dottori M, Bernhardsson S. Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain (PREVSAM): a randomised controlled trial protocol. BMC Musculoskelet Disord 2020; 21:790. [PMID: 33248457 PMCID: PMC7700707 DOI: 10.1186/s12891-020-03790-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Musculoskeletal pain is globally a leading cause of physical disability. Many musculoskeletal-related pain conditions, such as low back pain, often resolve spontaneously. In some individuals, pain may recur or persist, leading to ong-term physical disability, reduced work capacity, and sickness absence. Early identification of individuals in which this may occur, is essential for preventing or reducing the risk of developing persistent musculoskeletal pain and long-term sickness absence. The aim of the trial described in this protocol is to evaluate effects of an early intervention, the PREVSAM model, on the prevention of sickness absence and development of persistent pain in at-risk patients with musculoskeletal pain. METHODS Eligible participants are adults who seek health care for musculoskeletal pain and who are at risk of developing persistent pain, physical disability, and sickness absence. Participants may be recruited from primary care rehabilitation centres or primary care healthcare centres in Region Västra Götaland. Participants will be randomised to treatment according to the PREVSAM model (intervention group) or treatment as usual (control group). The PREVSAM model comprises an interdisciplinary, person-centred rehabilitation programme, including coordinated measures within primary health care, and may include collaboration with participants' employers. The primary outcome sickness absence is operationalised as the number and proportion of individuals who remain in full- or part-time work, the number of gross and net days of sickness absence during the intervention and follow-up period, and time to first sickness absence spell. Secondary outcomes are patient-reported short-term sickness absence, work ability, pain, self-efficacy, health-related quality of life, risk for sickness absence, anxiety and depression symptoms and physical disability at 1 and 3 months after inclusion (short-term follow-up), and at 6 and 12 months (long-term follow-up). A cost-effectiveness analysis is planned and drug consumption will be investigated. DISCUSSION The study is expected to provide new knowledge on the effectiveness of a comprehensive rehabilitation model that incorporates early identification of patients with musculoskeletal pain at risk for development of sickness absence and persistent pain. The study findings may contribute to more effective rehabilitation processes of this large patient population, and potentially reduce sickness absence and costs. TRIAL REGISTRATION ClinicalTrials.gov Protocol ID: NCT03913325 , Registered April 12, 2019. Version 2, 10 July 2020. Version 2 changes: Clarifications regarding trial aim and inclusion process.
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Affiliation(s)
- Meh Larsson
- Department of Education, Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden. .,Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | - L Nordeman
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Education, Research and Development Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - K Holmgren
- Unit of Occupational Therapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - A Grimby-Ekman
- School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - G Hensing
- School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - C Björkelund
- Primary Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - S Bergman
- Primary Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - A Ekhammar
- Department of Education, Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden.,Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - M Dottori
- Department of Education, Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
| | - S Bernhardsson
- Department of Education, Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden.,Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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19
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Ooms AG, Png ME, Cook JA, Dritsaki M, Dakin HA, Costa ML. Statistical and health economic analysis plan for a randomized controlled trial of surgical fixation with K-wires versus plaster casting in the treatment of dorsally displaced distal radius fractures: DRAFFT2. Bone Jt Open 2020; 1:245-252. [PMID: 33225296 PMCID: PMC7677726 DOI: 10.1302/2633-1462.16.bjo-2020-0044.r1] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aims Describe a statistical and economic analysis plan for the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) randomized controlled trial. Methods DRAFFT2 is a multicentre, parallel, two-arm randomized controlled trial. It compares surgical fixation with K-wires versus plaster cast in adult patients who have sustained a dorsally displaced fracture of the distal radius. The primary outcome measure is the Patient-Rated Wrist Evaluation (PRWE, a validated assessment of wrist function and pain) at 12 months post-randomization. Secondary outcomes are measured at three, six, and 12 months after randomization and include the PWRE, EuroQoL EQ-5D-5L index and EQ-VAS (visual analogue scale), complication rate, and cost-effectiveness of the treatment. Results This paper describes the full details of the planned methods of analysis and descriptive statistics. The DRAFFT2 study protocol has been published previously. Conclusion The planned analysis strategy described records our intent to conduct statistical and within-trial cost-utility analyses. Cite this article: Bone Joint Open 2020;1-6:245–252.
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Affiliation(s)
- Alexander Gert Ooms
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Helen A Dakin
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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20
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Bråten LCH, Grøvle L, Espeland A, Pripp AH, Grotle M, Helllum C, Haugen AJ, Froholdt A, Rolfsen MP, Nygaard ØP, Lutro O, Kristoffersen PM, Anke A, Schistad EI, Skouen JS, Brox JI, Zwart JA, Storheim K. Clinical effect modifiers of antibiotic treatment in patients with chronic low back pain and Modic changes - secondary analyses of a randomised, placebo-controlled trial (the AIM study). BMC Musculoskelet Disord 2020; 21:458. [PMID: 32660517 PMCID: PMC7359501 DOI: 10.1186/s12891-020-03422-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/15/2020] [Indexed: 01/13/2023] Open
Abstract
Background Randomised trials on antibiotic treatment for patients with chronic low back pain and vertebral endplate changes visible on MRI (Modic changes) have shown mixed results. A possible explanation might be a real treatment effect in subgroups of the study populations. The purpose of the present study was to explore potential clinical effect modifiers of 3-months oral amoxicillin treatment in patients with chronic low back pain and type I or II Modic changes at the level of a previous lumbar disc herniation. Methods We performed analyses of effect modifiers on data from AIM, a double-blind parallel-group multicentre trial. One hundred eighty patients with chronic low back pain, previous disc herniation, Modic change type I (n = 118) or type II (n = 62) were randomised to 3-months oral treatment with 750 mg amoxicillin (n = 89) or placebo (n = 91) three times daily. The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (possible values 0–24) at 1-year follow-up in the intention-to-treat population. The predefined minimal clinically important between-group mean difference was 4 RMDQ points (not reached in the primary analysis of AIM). Predefined baseline characteristics were analysed as potential effect modifiers, four primary (type I Modic changes, previous disc surgery, positive pain provocation test, high CRP) and five exploratory (disturbed sleep, constant low back pain, short duration of low back pain, younger age, and male) using ANCOVA with interaction terms. Results None of the four primary potential effect modifiers had strong evidence of modifying the treatment effect. In patients younger than 40 years the difference in mean RMDQ score between the treatment groups was − 4.0 (95%CI, − 6.9 to − 1.2), compared to − 0.5 (95%CI, − 2.3 to 1.3) in patients 40 years or older, both in favour of amoxicillin treatment (exploratory analysis). Conclusions We did not find evidence for convincing clinical effect modifiers of antibiotic treatment in patients with chronic low back pain and Modic changes. Our results for younger age in these explorative analyses should not affect clinical treatment decisions without confirmation in future studies. Trial registration ClinicalTrials.gov NCT02323412, First registered 23 December 2014.
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Affiliation(s)
- Lars Christian Haugli Bråten
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway. .,Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway.
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, PB 300, 1714, Grålum, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Klinisk institutt 1, Postboks 7804, NO-5020, Bergen, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Postbox 4950 Nydalen, 0424, Oslo, Norway
| | - Margreth Grotle
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, PO box 4 St. Olavs plass, NO-0130, Oslo, Norway
| | - Christian Helllum
- Department of Orthopaedic surgery, Oslo University Hospital, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Anne Julsrud Haugen
- Department of Rheumatology, Østfold Hospital Trust, PB 300, 1714, Grålum, Norway
| | - Anne Froholdt
- Department of Physical Medicine and Rehabilitation, Drammen Hospital, Vestre Viken Hospital Trust Drammen, Postboks 800, 3004, Drammen, Norway
| | - Mads Peder Rolfsen
- Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway.,Department of Orthopaedic surgery, Oslo University Hospital, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Øystein Petter Nygaard
- Department of Neurosurgery, St. Olavs University Hospital, Postbox 3250 Torgarden, NO-7006, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Faculty of Medicine and Health Sciences, N-7491, Trondheim, Norway.,National Advisory Unit on Spinal Surgery, St Olavs Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway
| | - Olav Lutro
- Stavanger University Hospital, Helse Stavanger HF, Postboks 8100, 4068, Stavanger, Norway
| | - Per Martin Kristoffersen
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Klinisk institutt 1, Postboks 7804, NO-5020, Bergen, Norway
| | - Audny Anke
- Department of Rehabilitation, University Hospital of North Norway, Postboks 100, 9038, Tromsø, Norway.,Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037, Tromsø, Norway
| | - Elina Iordanova Schistad
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ulleval, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Helse Bergen HF, Box 1, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Postboks 7804, NO-5020, Bergen, Norway
| | - Jens Ivar Brox
- Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway.,Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ulleval, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - John-Anker Zwart
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Faculty of Medicine, University of Oslo, PO BOX 1078 Blindern, 0316, Oslo, Norway
| | - Kjersti Storheim
- FORMI, Oslo University Hospital HF, Ulleval, Bygg 37b, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, PO box 4 St. Olavs plass, NO-0130, Oslo, Norway
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21
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Morton L, Siu ATY, Fowler S, Zhou C, Nixon C, Campbell D. A randomised controlled pilot trial of two interventions to manage dry mouth in pre-operative elective surgical patients. Pilot Feasibility Stud 2020; 6:89. [PMID: 32587752 PMCID: PMC7313130 DOI: 10.1186/s40814-020-00630-0] [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: 09/12/2019] [Accepted: 06/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Dry mouth is a common perioperative patient complaint. There are a number of treatments used for dry mouth in other settings which are effective. None have been tested previously in the perioperative setting. Interventions to Manage Dry mouth (IM DRY) compared the effect of water and a saliva substitute on mouth dryness. The primary objective was to demonstrate the feasibility of conducting a large randomised controlled trial and secondary scientific aims were to assess treatment potential efficacy. Methods Single blind, pilot randomised controlled trial (RCT) of 101 pre-operative elective surgical patients who were randomised to water or saliva substitute (Biotene oral rinse, GlaxoSmithKline, Australia) at a tertiary, university hospital. Dry mouth was assessed by 100 mm visual analogue scale (VAS) and 5-point Likert score. Results One hundred participants completed follow-up and comprised the analysis dataset. All feasibility outcomes were achieved (recruitment rate > 5 participants a week, >95% completeness of the dataset, study protocol acceptability to staff, acceptability to participants > 66% and adherence to time limits within the protocol). Mean recruitment rate was 6 participants per week. These data were 99% complete. There were no adverse side effects or complications noted. There were no concerns raised by staff regarding acceptability. Overall, there was a mean of 30 min (± SD 5 min) between delivery of the intervention and the assessment, 30 min being the target time. The difference in VAS post intervention was - 11.2 mm (95% CI - 17.3 to - 5.1 mm) for water and - 12.7 mm (95% CI - 18.7 to - 6.7 mm) for saliva substitute. The proportion of patients who had improved dry mouth increased from 52% for water to 62% for saliva substitute. Conclusions IM DRY successfully achieved its primary feasibility aims: recruitment rate, completeness of these, acceptability and protocol adherence. Saliva substitutes, used in the perioperative management of dry mouth, may be a simple, inexpensive, and low risk solution to help alleviate this common complaint. A large randomised controlled trial is feasible and is currently recruiting (ANZCTR 12619000132145). Ethics and Trial registration Northern A New Zealand Health and Disability Ethics Committee (reference 17/NTA/152). Australian New Zealand Clinical Trials Registry (Number: 12618001270202). Registered retrospectively 18 October 2018.
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Affiliation(s)
- Leesa Morton
- Department of Anaesthesia, Canterbury District Health Board, 2 Riccarton Avenue, Christchurch Central, Christchurch, 8011 New Zealand
| | - Amanda Tsan Yue Siu
- Department of Anaesthesia, Counties Manukau District Health Board, 100 Hospital Road, Otahuhu, Auckland 2025 New Zealand
| | - Samuel Fowler
- Department of Anaesthesia and Perioperative Medicine, Auckland District Health Board, Level 8, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland 1023 New Zealand
| | - Chen Zhou
- Department of Anaesthesia, Counties Manukau District Health Board, 100 Hospital Road, Otahuhu, Auckland 2025 New Zealand
| | - Christopher Nixon
- Department of Anaesthesia and Perioperative Medicine, Auckland District Health Board, Level 8, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland 1023 New Zealand
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland District Health Board, Level 8, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland 1023 New Zealand
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Bradshaw LE, Montgomery AA, Williams HC, Chalmers JR, Haines RH. Two-by-two factorial randomised study within a trial (SWAT) to evaluate strategies for follow-up in a randomised prevention trial. Trials 2020; 21:529. [PMID: 32546180 PMCID: PMC7296963 DOI: 10.1186/s13063-020-04373-4] [Citation(s) in RCA: 4] [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: 01/07/2020] [Accepted: 05/05/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Failure to collect outcome data in randomised trials can result in bias and loss of statistical power. Further evaluations of strategies to increase retention are required. We assessed the effectiveness of two strategies for retention in a randomised prevention trial using a two-by-two factorial randomised study within a trial (SWAT). METHODS Parents of babies included in the host trial were randomised to (1) short message service (SMS) notification prior to sending questionnaires at 3, 6, 12 and 18 months versus no SMS notification and (2) a £10 voucher sent with the invitation letter for the primary follow-up visit at 24 months or given at the visit. The two co-primary outcomes were collection of host trial (1) questionnaire data at interim follow-up times and (2) primary outcome at 24 months during a home/clinic visit with a research nurse. RESULTS Between November 2014 and November 2016, 1394 participants were randomised: 350 to no SMS + voucher at visit, 345 to SMS + voucher at visit, 352 to no SMS + voucher before visit and 347 to SMS + voucher before visit. Overall questionnaire data was collected at interim follow-up times for 75% in both the group allocated to the prior SMS notification and the group allocated to no SMS notification (odds ratio (OR) SMS versus none 1.02, 95% CI 0.83 to 1.25). Host trial primary outcome data was collected at a visit for 557 (80%) allocated to the voucher before the visit in the invitation letter and for 566 (81%) whose parents were allocated to receive the voucher at the visit (OR before versus at visit 0.89, 95% CI 0.69 to 1.17). CONCLUSION There was no evidence of a difference in retention according to SMS notification or voucher timing. Future synthesis of SWAT results is required to be able to detect small but important incremental effects of retention strategies. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN21528841. Registered on 25 July 2014. SWAT Repository Store ID 25.
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Affiliation(s)
- Lucy E. Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR UK
| | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR UK
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
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Mafham MM, Bowman LJ, Haynes RJ, Armitage JM. Streamlined mail-based methods for large randomised trials: lessons learnt from the ASCEND study. Diabetologia 2020; 63:898-905. [PMID: 31786655 PMCID: PMC7145772 DOI: 10.1007/s00125-019-05049-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/22/2019] [Indexed: 01/21/2023]
Abstract
Reliable assessment of the effects of an intervention usually requires large randomised trials but such studies are becoming increasingly complex and costly to run. 'Streamlined' trials are needed in which every aspect of the trial design and conduct is simplified, retaining only those elements needed to answer the research question and ensure the safety of the individual participants. In this review we discuss how the trial 'A Study of Cardiovascular Events iN Diabetes' (ASCEND) was streamlined. The study included a two-by-two factorial design: it assessed the effects of low-dose aspirin and, separately, supplementation with n-3 fatty acids on serious vascular events in 15,480 people with diabetes but no overt cardiovascular disease. Other key streamlined design features, such as mail-based recruitment and follow-up, mainly by post, with no in-person visits and use of a run-in period, are also described. We go on to discuss the success of the study and other studies that have employed a similar mail-based approach, and the type of clinical trials that are suitable for mail-based design. Finally, we consider the limitations of the study, and how these could be circumvented in future studies. ASCEND randomised large numbers of eligible participants, achieved good adherence rates and almost complete follow-up at a fraction of the cost of traditional clinic-based trials. Such studies are necessary if researchers are to address the important clinical questions most relevant to improving health.
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Affiliation(s)
- Marion M Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK.
| | - Louise J Bowman
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard J Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane M Armitage
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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24
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A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol. Trials 2020; 21:71. [PMID: 31931848 PMCID: PMC6956478 DOI: 10.1186/s13063-019-3829-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention. METHODS ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment. DISCUSSION Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines. TRIAL REGISTRATION Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.
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Buckley HL, Collinson FJ, Ainsworth G, Poad H, Flanagan L, Katona E, Howard HC, Murden G, Banks RE, Brown J, Velikova G, Waddell T, Fife K, Nathan PD, Larkin J, Powles T, Brown SR, Vasudev NS. PRISM protocol: a randomised phase II trial of nivolumab in combination with alternatively scheduled ipilimumab in first-line treatment of patients with advanced or metastatic renal cell carcinoma. BMC Cancer 2019; 19:1102. [PMID: 31727024 PMCID: PMC6854710 DOI: 10.1186/s12885-019-6273-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 08/19/2019] [Accepted: 10/18/2019] [Indexed: 01/07/2023] Open
Abstract
Background The combination of nivolumab, a programmed death-1 (PD-1) targeted monoclonal antibody, with the cytotoxic T-lymphocyte antigen-4 (CTLA-4) targeted antibody, ipilimumab, represents a new standard of care in the first-line setting for patients with intermediate- and poor-risk metastatic renal cell carcinoma (mRCC) based on recent phase III data. Combining ipilimumab with nivolumab increases rates of grade 3 and 4 toxicity compared with nivolumab alone, and the optimal scheduling of these agents when used together remains unknown. The aim of the PRISM study is to assess whether less frequent dosing of ipilimumab (12-weekly versus 3-weekly), in combination with nivolumab, is associated with a favourable toxicity profile without adversely impacting efficacy. Methods The PRISM trial is a UK-based, open label, multi-centre, phase II, randomised controlled trial. The trial population consists of patients with untreated locally advanced or metastatic clear cell RCC, and aims to recruit 189 participants. Participants will be randomised on a 2:1 basis in favour of a modified schedule of 4 doses of 12-weekly ipilimumab versus a standard schedule of 4 doses of 3-weekly ipilimumab, both in combination with standard nivolumab. The proportion of participants experiencing a grade 3 or 4 adverse reaction within 12 months forms the primary endpoint of the study, but with 12-month progression free survival a key secondary endpoint. The incidence of all adverse events, discontinuation rates, overall response rate, duration of response, overall survival rates and health related quality of life will also be analysed as secondary endpoints. In addition, the potential of circulating and tissue-based biomarkers as predictors of therapy response will be explored. Discussion The combination of nivolumab with ipilimumab is active in patients with mRCC. Modifying the frequency of ipilimumab dosing may mitigate toxicity rates and positively impact quality of life without compromising efficacy, a hypothesis being explored in other tumour types such as non-small cell lung cancer. The best way to give this combination to patients with mRCC must be similarly established. Trial registration PRISM is registered with ISRCTN (reference ISRCTN95351638, 19/12/2017). Trial status At the time of submission, PRISM is open to recruitment and data collection is ongoing.
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Affiliation(s)
- Hannah L Buckley
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Fiona J Collinson
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Heather Poad
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Louise Flanagan
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Eszter Katona
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Helen C Howard
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Geraldine Murden
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Rosamonde E Banks
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Joanne Brown
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | | | - Tom Waddell
- Department of Medical Oncology, Christie Hospital, Manchester, M20 4BX, UK
| | - Kate Fife
- Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | | | | | | | - Sarah R Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Naveen S Vasudev
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
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26
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Helen T, Liz C, Laura C, Illary S, Martin B, Hannah B, Ian C, Jo D, Chris F, Rachael F, Rhian G, Keith H, Alison L, Ellie L, Catriona MD, Christine M, Debbie R, Gerard S, David T, Peter V, Laurie W, Robert H. Aspirin versus placebo for the treatment of venous leg ulcers-a phase II, pilot, randomised trial (AVURT). Trials 2019; 20:459. [PMID: 31349862 PMCID: PMC6660698 DOI: 10.1186/s13063-019-3480-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/19/2017] [Accepted: 05/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) can take many months to heal and 25% fail to heal. The main treatment for venous leg ulcers is compression therapy and few additional therapies exist. Two previous trials indicated that low-dose aspirin may improve healing time, but these trials were insufficiently robust. METHODS A multi-centred, pilot, phase II, randomised, double blind, parallel-group, placebo-controlled, efficacy trial (RCT) was conducted to determine: if aspirin improves VLU healing time; the safety of aspirin in this population; treatment compliance; and the feasibility of recruitment to a phase III trial. We recruited patients from secondary care who were aged ≥ 18 years, had a chronic VLU and not regularly taking aspirin. Participants were randomly assigned (1:1) to receive 300 mg of daily aspirin or placebo in addition to standard care, which consisted of multi component compression therapy aiming to deliver 40 mmHg at the ankle where possible. The randomisation list was stratified by ulcer size (≤ 5 cm2 or > 5 cm2). The primary endpoint was time to ulcer healing, which was defined as 'complete epithelial healing in the absence of scab (eschar) with no dressing required'. Safety outcomes were assessed in all participants who received at least one dose of the study drug. RESULTS Twenty-seven patients were recruited from eight sites (target 100 patients). A short time-frame to recruit and a large number of patients failing to meet the eligibility criteria were the main barriers to recruitment. There was no evidence of a difference in time to healing of the reference ulcer following adjustment for log ulcer area and duration (hazard ratio 0.58, 95% confidence interval 0.18 to 1.85; p = 0.357). One expected serious adverse event related to aspirin was recorded. A number of options to improve recruitment were explored. CONCLUSIONS There was no evidence that aspirin was effective in expediting the healing of chronic VLUs. However, the analysis was underpowered due to the low number of participants recruited. The trial design would require substantial amendment in order to progress to a phase III (effectiveness) trial. TRIAL REGISTRATION Clinicaltrials.gov, NCT02333123. Registered on 5 November 2014.
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Affiliation(s)
- Tilbrook Helen
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Cook Liz
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Clark Laura
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Sbizzera Illary
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Bland Martin
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Buckley Hannah
- Cancer Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Chetter Ian
- Academic Vascular Surgical Unit, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ UK
| | - Dumville Jo
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL UK
| | - Fenner Chris
- Orthopaedic Department, West Middlesex Hospital, Twickenham Road, Isleworth, Middlesex, TW9 1UR UK
| | - Forsythe Rachael
- Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Gabe Rhian
- Hull York Medical School & York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Harding Keith
- Wound Healing, Cardiff University, School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - Layton Alison
- Harrogate and District NHS Foundation Trust, Lancaster Park Road, Harrogate, HG2 7SX UK
| | - Lindsay Ellie
- (Lay representative). The Lindsay Leg Club Foundation, PO Box 689, Ipswich, IP1 9BN UK
| | - Mc Daid Catriona
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Moffatt Christine
- The University of Nottingham, School of Health Sciences, Derby Education Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT UK
| | - Rolfe Debbie
- Joint Research and Enterprise Office, St Georges University of London, Cranmer Terrace, London, SW17 0RE UK
| | - Stansby Gerard
- Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN UK
| | - Torgerson David
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD UK
| | - Vowden Peter
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ UK
| | - Williams Laurie
- (Lay representative). The Lindsay Leg Club Foundation, PO Box 689, Ipswich, IP1 9BN UK
| | - Hinchliffe Robert
- Bristol Centre for Surgical Research, Bristol NIHR Biomedical Research Centre, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
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27
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Al-Laith M, Jasenecova M, Abraham S, Bosworth A, Bruce IN, Buckley CD, Ciurtin C, D'Agostino MA, Emery P, Gaston H, Isaacs JD, Filer A, Fisher BA, Huizinga TWJ, Ho P, Jacklin C, Lempp H, McInnes IB, Pratt AG, Östor A, Raza K, Taylor PC, van Schaardenburg D, Shivapatham D, Wright AJ, Vasconcelos JC, Kelly J, Murphy C, Prevost AT, Cope AP. Arthritis prevention in the pre-clinical phase of RA with abatacept (the APIPPRA study): a multi-centre, randomised, double-blind, parallel-group, placebo-controlled clinical trial protocol. Trials 2019; 20:429. [PMID: 31307535 PMCID: PMC6633323 DOI: 10.1186/s13063-019-3403-7] [Citation(s) in RCA: 70] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/06/2019] [Indexed: 01/01/2023] Open
Abstract
TRIAL DESIGN We present a study protocol for a multi-centre, randomised, double-blind, parallel-group, placebo-controlled trial that seeks to test the feasibility, acceptability and effectiveness of a 52-week period of treatment with the first-in-class co-stimulatory blocker abatacept for preventing or delaying the onset of inflammatory arthritis. METHODS The study aimed to recruit 206 male or female subjects from the secondary care hospital setting across the UK and the Netherlands. Participants who were at least 18 years old, who reported inflammatory sounding joint pain (clinically suspicious arthralgia) and who were found to be positive for serum autoantibodies associated with rheumatoid arthritis (RA) were eligible for enrolment. All study subjects were randomly assigned to receive weekly injections of investigational medicinal product, either abatacept or placebo treatment over the course of a 52-week period. Participants were followed up for a further 52 weeks. The primary endpoint was defined as the time to development of at least three swollen joints or to the fulfilment of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for RA using swollen but not tender joints, whichever endpoint was met first. In either case, swollen joints were confirmed by ultrasonography. Participants, care givers, and those assessing the outcomes were all blinded to group assignment. Clinical assessors and ultrasonographers were also blinded to each other's assessments for the duration of the study. CONCLUSIONS There is limited experience of the design and implementation of trials for the prevention of inflammatory joint diseases. We discuss the rationale behind choice and duration of treatment and the challenges associated with defining the "at risk" state and offer pragmatic solutions in the protocol to enrolling subjects at risk of RA. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN46017566 . Registered on 4 July 2014.
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Affiliation(s)
- Mariam Al-Laith
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
| | - Marianna Jasenecova
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Sonya Abraham
- Department of Rheumatology, National Institute for Health Research-Wellcome Clinical Research Facility, Hammersmith Hospital, Imperial College, London, W12 0HS, UK
| | - Aisla Bosworth
- National RA Society, The Switchback Office Park, Gardner Road, Maidenhead, SL6 7RJ, UK
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- National Institute for Health Research Biomedical Research Centre and the Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Christopher D Buckley
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Coziana Ciurtin
- Department of Adolescent and Adult Rheumatology, University College London Hospitals NHS Trust, 3rd Floor Central, 250 Euston Road, London, NW1 2PG, UK
| | - Maria-Antonietta D'Agostino
- Rheumatology Department, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Paul Emery
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK NIHR Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, LS4 7SA, UK
| | - Hill Gaston
- Department of Medicine, University of Cambridge and Addenbrookes Hospital NHS Trust, Cambridge, UK
| | - John D Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, 3rd Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Benjamin A Fisher
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Thomas W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pauline Ho
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- National Institute for Health Research Biomedical Research Centre and the Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Clare Jacklin
- National RA Society, The Switchback Office Park, Gardner Road, Maidenhead, SL6 7RJ, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, 120 University Place, Glasgow, G12 8TA, UK
| | - Arthur G Pratt
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, 3rd Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Östor
- Department of Medicine, University of Cambridge and Addenbrookes Hospital NHS Trust, Cambridge, UK
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and immunology Center, locations Reade and Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dharshene Shivapatham
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Alison J Wright
- Clinical, Education & Health Psychology Division of Psychology & Language Sciences, Faculty of Brain Sciences, University College London, London, WC1E 6BT, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London, SE5 8AF, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
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Reza M, Wirth M, Tammela T, Cicalese V, Veiga FG, Mulders P, Miller K, Tubaro A, Debruyne F, Patel A, Caris C, Witjes W, Thorsson O, Wollmer P, Edenbrandt L, Ohlsson M, Trägårdh E, Bjartell A. Automated Bone Scan Index as an Imaging Biomarker to Predict Overall Survival in the Zometa European Study/SPCG11. Eur Urol Oncol 2021; 4:49-55. [PMID: 31186177 DOI: 10.1016/j.euo.2019.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/18/2019] [Accepted: 05/14/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Owing to the large variation in treatment response among patients with high-risk prostate cancer, it would be of value to use objective tools to monitor the status of bone metastases during clinical trials. Automated Bone Scan Index (aBSI) based on artificial intelligence has been proposed as an imaging biomarker for the quantification of skeletal metastases from bone scintigraphy. OBJECTIVE To investigate how an increase in aBSI during treatment may predict clinical outcome in a randomised controlled clinical trial including patients with high-risk prostate cancer. DESIGN, SETTING, AND PARTICIPANTS We retrospectively selected all patients from the Zometa European Study (ZEUS)/SPCG11 study with image data of sufficient quality to allow for aBSI assessment at baseline and at 48-mo follow-up. Data on aBSI were obtained using EXINIboneBSI software, blinded for clinical data and randomisation of zoledronic acid treatment. Data on age, overall survival (OS), and prostate-specific antigen (PSA) at baseline and upon follow-up were available from the study database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Association between clinical parameters and aBSI increase during treatment was evaluated using Cox proportional-hazards regression models, Kaplan-Meier estimates, and log-rank test. Discrimination between prognostic variables was assessed using the concordance index (C-index). RESULTS AND LIMITATIONS In this cohort, 176 patients with bone metastases and a change in aBSI from baseline to follow-up of ≤0.3 had a significantly longer median survival time than patients with an aBSI change of >0.3 (p<0.0001). The increase in aBSI was significantly associated with OS (p<0.01 and C-index=0.65), while age and PSA change were not. CONCLUSIONS The aBSI used as an objective imaging biomarker predicted outcome in prostate cancer patients in the ZEUS/SPCG11 study. An analysis of the change in aBSI from baseline to 48-mo follow-up represents a valuable tool for prognostication and monitoring of prostate cancer patients with bone metastases. PATIENT SUMMARY The increase in the burden of skeletal metastases, as measured by the automated Bone Scan Index (aBSI), during treatment was associated with overall survival in patients from the Zometa European Study/SPCG11 study. The aBSI may be a useful tool also in monitoring prostate cancer patients with newly developed bone metastases.
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Coton J, Le HH, Veuillet V, Janiaud P, Cucherat M, Kassai-Koupai B, Gueyffier F, Reix P. Do patients with cystic fibrosis participating in clinical trials demonstrate placebo response? A meta-analysis. J Cyst Fibros 2019; 18:461-467. [PMID: 30772244 DOI: 10.1016/j.jcf.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients' and families' expectation that a cure for cystic fibrosis (CF) will be found is high. In other debilitating conditions, high expectation has been shown to drive a strong placebo response (PR). Therefore, our goal was to evaluate PR on objective continuous outcomes (FEV1, BMI) and the CF Questionnaire Revised-Respiratory Domain (CFQR-RD) monitored during randomised clinical trials (RCTs) for CF. METHODS We conducted a meta-analysis after a systematic review of the literature carried out to identify RCTs with FEV1, CFQR-RD and BMI as outcome measures. The standardised mean difference (SMD) was calculated to estimate the PR. A meta-regression analysis was conducted to assess other contributing factors on PR such as study design, trial duration, patient age and disease severity. RESULTS Out of 289 RCTs found in the search, we identified 61 articles (published from 1987 to 2017) with respectively 59, 17 and 9 reporting FEV1, CFQR-RD and BMI at the start and at the end of the RCTs. No significant PR was found on FEV1 or CFQR-RD. However, a small but significant PR was found on BMI SMD, 0.09 (95% CI (0.01; 0.17); p = 0.03). CONCLUSION The PR seems higher when measuring BMI. However, it is not clear whether this improvement can be explained by a PR alone.
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Affiliation(s)
- Julie Coton
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; Centre de ressources et de compétences de la mucoviscidose, Hospices Civils de Lyon, Lyon, France
| | - Ha-Hai Le
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France
| | - Victor Veuillet
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France
| | - Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
| | - Michel Cucherat
- Department of Clinical Pharmacology, Université Claude Bernard Lyon 1, Lyon, France
| | - Behrouz Kassai-Koupai
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; EPICIME-Clinical Investigation Center, INSERM CIC1407/UMR5558, Bron, France
| | - François Gueyffier
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; EPICIME-Clinical Investigation Center, INSERM CIC1407/UMR5558, Bron, France
| | - Philippe Reix
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; Centre de ressources et de compétences de la mucoviscidose, Hospices Civils de Lyon, Lyon, France.
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Verdelho A, Madureira S, Correia M, Ferro JM, Rodrigues M, Gonçalves-Pereira M, Gonçalves M, Santos AC, Vilela P, Bárrios H, Borges M, Santa-Clara H. Impact of physical activity in vascular cognitive impairment (AFIVASC): study protocol for a randomised controlled trial. Trials 2019; 20:114. [PMID: 30744681 PMCID: PMC6371566 DOI: 10.1186/s13063-019-3174-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 01/02/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Cognitive impairment and cerebrovascular pathology are both frequent with ageing. Cognitive impairment due to vascular pathology of the brain, termed vascular cognitive impairment (VCI), is one of the most frequent causes of cognitive impairment in elderly subjects. Thus far, VCI has no specific pharmacological treatment. Recent observational studies have suggested a protective effect of physical activity in cognition, but adequate randomised controlled trials (RCT) are lacking. METHODS AFIVASC is a multi-centre randomised controlled trial, with a 6-month intervention treatment and an additional follow-up of 6 months, that aims to estimate the impact of 6 months of moderate intensity physical activity on cognition (the primary outcome) at 6 and 12 months in subjects with VCI. Participants are community dwellers with criteria for VCI without dementia or who have had previous stroke or transient ischaemic attack (TIA). Patients may be self-referred or referred from a medical appointment. After confirming the inclusion criteria, a run-in period of 1 month is conducted to access adherence; only after that are subjects randomly assigned (using a computerised program blinded to clinical details) to two groups (intervention group and best practice usual care group). The intervention consists of three physical activity sessions of 60 min each (two supervised and one unsupervised) per week. The primary outcome is measured by the presence or absence of decline in cognitive status. Secondary outcomes include changes in neuro-cognitive measures, quality of life, and functional and motor status. Primary and secondary outcomes are evaluated at 6 and 12 months by investigators blinded to both intervention and randomisation. A required sample size of 280 subjects was estimated. Statistical analyses will include regression analysis with repeated measures. The study was approved by the Ethics Committee for Health of Centro Hospitalar de Lisboa Norte (ref. no. 1063/13) and by the Ethics Committee for Health of Centro Hospitalar do Porto CHP (ref. no. 2016.055(049-DEFI/048-CES)). DISCUSSION We aim to show whether or not moderate physical activity has a beneficial impact on cognition, quality of life, motor, and functional status in people with vascular cognitive impairment, and to generate new insights on the applicability of implementing physical activity in this specific population. TRIAL REGISTRATION ClinicalTrials.gov, NCT03578614 July 6, 2018.
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Affiliation(s)
- Ana Verdelho
- Department of Neurosciences and Mental Health, Faculdade de Medicina, Centro Hospitalar Universitário Lisboa Norte Hospital de Santa Maria, Instituto de Medicina Molecular (IMM) and Instituto de Saúde Ambiental (ISAMB), Universidade de Lisboa, Avenida Professor Egas Moniz, 1649035 Lisbon, Portugal
| | - Sofia Madureira
- Department of Psychology, ISCTE-IUL, NOVA Medical School / Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Instituto de Medicina Molecular (IMM), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Manuel Correia
- Neurology Service, Hospital de Santo António, Centro Hospitalar do Porto and Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - José Manuel Ferro
- Instituto de Medicina Molecular (IMM), Faculdade de Medicina, Universidade de Lisboa and Department of Neuroscience, Hospital de Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mário Rodrigues
- Instituto de Medicina Molecular (IMM), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Manuel Gonçalves-Pereira
- CEDOC, Chronic Diseases Research Center, NOVA Medical School /Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Mafalda Gonçalves
- Instituto de Medicina Molecular (IMM), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Catarina Santos
- Instituto de Medicina Molecular (IMM), Faculdade de Medicina, Universidade de Lisboa and Dementia Unit, Hospital do Mar, Lisbon, Portugal
| | - Pedro Vilela
- Neuroradiology - Imaging Department, Hospital da Luz, Lisbon, Portugal
| | - Helena Bárrios
- NOVA Medical School, Universidade Nova de Lisboa, Portugal and Instituto de Medicina Molecular (IMM), Hospital do Mar Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mariana Borges
- Instituto de Medicina Molecular (IMM), Faculdade de Medicina, Universidade de Lisboa and Faculdade de Motricidade Humana,Universidade de Lisboa, Lisbon, Portugal
| | - Helena Santa-Clara
- Faculdade de Motricidade Humana, Universidade de Lisboa, CIPER – Centro Interdisciplinar de Estudo da Performance Humana, Lisbon, Portugal
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Gupta PK, Acharya A, Mourya A, Mahajan P. Comparison of patellar tendon versus hamstrings autografts for anterior cruciate ligament reconstruction in Indian population: A randomised control trial study. J Clin Orthop Trauma 2019; 10:581-585. [PMID: 31061594 PMCID: PMC6494777 DOI: 10.1016/j.jcot.2018.04.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 03/30/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022] Open
Abstract
UNLABELLED Disruption of anterior cruciate ligament (ACL) is a common ligamentous injury of the knee. The best choice of graft for reconstruction remains undecided. This prospective, randomized clinical trial aimed to compare clinical results of bone-patellar tendon-bone (BPTB) grafts and four-strand semitendinosus-gracilis (QHT) grafts for ACL reconstruction over a 1-year follow-up interval in Indian population. METHODS 42 consecutive patients with ACL injury were recruited, by pick and draw method and allotted into two groups with 21 patients in each group. Group A patients underwent arthroscopic ACL reconstruction using BPTB graft while QHT autograft was used for patients in Group B. All the patients underwent standard ipsilateral arthroscopic ACL reconstruction procedure using a single incision, antero-medial (AM) portal technique for BPTB or the QHT autograft by a same surgeon. Patients were followed up regularly for a minimum period of 1 year. RESULTS After one year, the Cincinnati score was 91 ± 4.117 in BPTB group and 89.29 ± 5.371 in QHT group (P = 0.282). There was no significant difference between the two groups in the mean scores with respect to pain, overall activity level and running in the Cincinnati score. None of the patients complained of the knee giving way. Similarly, at 1 year, the Lysholm score was 92.84 ± 2.630 and 90.55 ± 2.395 in the two groups respectively (P = 0.842). There were no episodes of locking or instability and there was no significant difference in the mean Lysholm scores regarding pain and squatting. CONCLUSION There was no significant functional difference between the two grafts in terms of Lysholm and the Cincinnati score, anterior knee laxity and altered sensation over proximal leg. The patients with QHT groups performed better than BPTB functionally at 6 month so early return to sport is possible even with QHT autograft.
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Affiliation(s)
- Prateek Ku Gupta
- Sir Gangaram hospital, New Delhi, India,Corresponding author at: C 2/5, SDA, marg, New Delhi, India.
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Seddon JA, Garcia-Prats AJ, Purchase SE, Osman M, Demers AM, Hoddinott G, Crook AM, Owen-Powell E, Thomason MJ, Turkova A, Gibb DM, Fairlie L, Martinson N, Schaaf HS, Hesseling AC. Levofloxacin versus placebo for the prevention of tuberculosis disease in child contacts of multidrug-resistant tuberculosis: study protocol for a phase III cluster randomised controlled trial (TB-CHAMP). Trials 2018; 19:693. [PMID: 30572905 PMCID: PMC6302301 DOI: 10.1186/s13063-018-3070-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 12/20/2017] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant (MDR) tuberculosis (TB) presents a challenge for global TB control. Treating individuals with MDR-TB infection to prevent progression to disease could be an effective public health strategy. Young children are at high risk of developing TB disease following infection and are commonly infected by an adult in their household. Identifying young children with household exposure to MDR-TB and providing them with MDR-TB preventive therapy could reduce the risk of disease progression. To date, no trials of MDR-TB preventive therapy have been completed and World Health Organization guidelines suggest close observation with no active treatment. METHODS The tuberculosis child multidrug-resistant preventive therapy (TB-CHAMP) trial is a phase III cluster randomised placebo-controlled trial to assess the efficacy of levofloxacin in young child contacts of MDR-TB cases. The trial is taking place at three sites in South Africa where adults with MDR-TB are identified. If a child aged < 5 years lives in their household, we assess the adult index case, screen all household members for TB disease and evaluate any child aged < 5 years for trial eligibility. Eligible children are randomised by household to receive daily levofloxacin (15-20 mg/kg) or matching placebo for six months. Children are closely monitored for disease development, drug tolerability and adverse events. The primary endpoint is incident TB disease or TB death by one year after recruitment. We will enrol 1556 children from approximately 778 households with an average of two eligible children per household. Recruitment will run for 18-24 months with all children followed for 18 months after treatment. Qualitative and health economic evaluations are embedded in the trial. DISCUSSION If the TB-CHAMP trial demonstrates that levofloxacin is effective in preventing TB disease in young children who have been exposed to MDR-TB and that it is safe, well tolerated, acceptable and cost-effective, we would expect that that this intervention would rapidly transfer into policy. TRIAL REGISTRATION ISRCTN Registry, ISRCTN92634082 . Registered on 31 March 2016.
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Affiliation(s)
- James A. Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, Norfolk Place, London, W2 1PG UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Susan E. Purchase
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Angela M. Crook
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Ellen Owen-Powell
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Margaret J. Thomason
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M. Gibb
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Lee Fairlie
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
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Kessoku T, Imajo K, Kobayashi T, Honda Y, Kato T, Ogawa Y, Tomeno W, Kato S, Higurashi T, Yoneda M, Kirikoshi H, Kubota K, Taguri M, Yamanaka T, Usuda H, Wada K, Saito S, Nakajima A. Efficacy, safety, and tolerability of lubiprostone for the treatment of non-alcoholic fatty liver disease in adult patients with constipation: The LUBIPRONE, double-blind, randomised, placebo-controlled study design. Contemp Clin Trials 2018; 69:40-47. [PMID: 29627620 DOI: 10.1016/j.cct.2018.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND This paper reports the protocol of a randomised, double-blind, placebo-controlled study to test the efficacy, safety, and tolerability of lubiprostone (LUB) vs. placebo on suppressing gut permeability in non-alcoholic fatty liver disease (NAFLD) patients with constipation. NAFLD, including non-alcoholic steatohepatitis (NASH), is a common chronic liver disorder. Progression is associated with increased gut permeability and gut-derived endotoxins. Most NAFLD/NASH clinical trial drugs aim to improve liver function or systemic metabolism. LUB is a type 2 chloride channel activator used as a laxative for the treatment of patients with constipation. LUB suppresses gut permeability induced by non-steroidal anti-inflammatory drugs in healthy volunteers and lowers blood endotoxin levels. There have been no clinical studies of LUB for NAFLD/NASH patients. METHODS The study plans to enrol adult patients (20-85 years, planned enrolment, n = 150; planned sample size, n = 120) with NAFLD and constipation, alanine aminotransferase ≥40 IU/L, equivalent steatosis grade ≥1, and equivalent fibrosis stage <4 measured using non-invasive vibration-controlled transient elastography and magnetic resonance imaging. Participants will be randomly allocated into three groups: LUB 12 μg, LUB 24 μg, and a placebo group. RESULTS The primary endpoint will be changes in alanine aminotransferase from baseline at 12 weeks. The main secondary endpoint will be changes in intestinal permeability from baseline at 12 weeks using the lactulose mannitol ratio. CONCLUSIONS This study will determine whether LUB improves gut permeability in NAFLD patients with constipation. TRIAL REGISTRATION This trial is registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000026635).
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Affiliation(s)
- Takaomi Kessoku
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Kento Imajo
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Yasushi Honda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Takayuki Kato
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Yuji Ogawa
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Wataru Tomeno
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hiroyuki Kirikoshi
- Clinical Laboratory Department, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Kazumi Kubota
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Masataka Taguri
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Takeharu Yamanaka
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Haruki Usuda
- Department of Pharmacology, Shimane University School of Medicine, 89-1, Enyacho, Izumo, Shimane 693-8501, Japan.
| | - Koichiro Wada
- Department of Pharmacology, Shimane University School of Medicine, 89-1, Enyacho, Izumo, Shimane 693-8501, Japan.
| | - Satoru Saito
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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Aramburo A, Todd J, George EC, Kiguli S, Olupot-Olupot P, Opoka RO, Engoru C, Akech SO, Nyeko R, Mtove G, Gibb DM, Babiker AG, Maitland K. Lactate clearance as a prognostic marker of mortality in severely ill febrile children in East Africa. BMC Med 2018; 16:37. [PMID: 29519240 PMCID: PMC5844084 DOI: 10.1186/s12916-018-1014-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hyperlactataemia (HL) is a biomarker of disease severity that predicts mortality in patients with sepsis and malaria. Lactate clearance (LC) during resuscitation has been shown to be a prognostic factor of survival in critically ill adults, but little data exist for African children living in malaria-endemic areas. METHODS In a secondary data analysis of severely ill febrile children included in the Fluid Expansion as Supportive Therapy (FEAST) resuscitation trial, we assessed the association between lactate levels at admission and LC at 8 h with all-cause mortality at 72 h (d72). LC was defined as a relative lactate decline ≥ 40% and/or lactate normalisation (lactate < 2.5 mmol/L). RESULTS Of 3170 children in the FEAST trial, including 1719 children (57%) with Plasmodium falciparum malaria, 3008 (95%) had a baseline lactate measurement, 2127 (71%) had HL (lactate ≥ 2.5 mmol/L), and 1179 (39%) had severe HL (≥ 5 mmol/L). Within 72 h, 309 children (10.3%) died, of whom 284 (92%) had baseline HL. After adjustment for potential confounders, severe HL was strongly associated with mortality (Odds Ratio (OR) 6.96; 95% CI 3.52, 13.76, p < 0.001). This association was not modified by malaria status, despite children with malaria having a higher baseline lactate (median 4.6 mmol/L vs 3 mmol/L; p < 0.001) and a lower mortality rate (OR = 0.42; p < 0.001) compared to non-malarial cases. Sensitivity and specificity analysis identified a higher lactate on admission cut-off value predictive of d72 for children with malaria (5.2 mmol/L) than for those with other febrile illnesses (3.4 mmol/L). At 8 h, 2748/3008 survivors (91%) had a lactate measured, 1906 (63%) of whom had HL on admission, of whom 1014 (53%) fulfilled pre-defined LC criteria. After adjustment for confounders, LC independently predicted survival after 8 h (OR 0.24; 95% CI 0.14, 0.42; p < 0.001). Absence of LC (< 10%) at 8 h was strongly associated with death at 72 h (OR 4.62; 95% CI 2.7, 8.0; p < 0.001). CONCLUSIONS Independently of the underlying diagnosis, HL is a strong risk factor for death at 72 h in children admitted with severe febrile illnesses in Africa. Children able to clear lactate within 8 h had an improved chance of survival. These findings prompt the more widespread use of lactate and LC to identify children with severe disease and monitor response to treatment. TRIAL REGISTRATION ISRCTN69856593 Registered 21 January 2009.
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Affiliation(s)
- A Aramburo
- Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
| | - Jim Todd
- London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place WC1H 9SH, London, WC1H 9SH, UK
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, 125 Aviation House, Kingsway, London, WC2B 6NH, UK
| | - Sarah Kiguli
- Department of Paediatrics, Mulago Hospital, Makerere College of Health Sciences, PO Box 7072, Kampala, Uganda
| | - Peter Olupot-Olupot
- Department of Paediatrics, Mbale Regional Referral Hospital, Pallisa Road, PO Box 291, Mbale, Uganda.,Mbale Clinical Research Institute (MCRI), Plot 29-33 Pallisa Rd, PO Box 1966, Mbale, Uganda
| | - Robert O Opoka
- Department of Paediatrics, Mulago Hospital, Makerere College of Health Sciences, PO Box 7072, Kampala, Uganda
| | - Charles Engoru
- Department of Paediatrics, Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Samuel O Akech
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 203, Nairobi, Kenya
| | | | | | - Diana M Gibb
- Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, 125 Aviation House, Kingsway, London, WC2B 6NH, UK
| | - Abdel G Babiker
- Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, 125 Aviation House, Kingsway, London, WC2B 6NH, UK
| | - Kathryn Maitland
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 203, Nairobi, Kenya. .,Department of Paediatrics, Faculty of Medicine, Imperial College, W2 1PG, London, UK.
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Striha A, Ashcroft AJ, Hockaday A, Cairns DA, Boardman K, Jacques G, Williams C, Snowden JA, Garg M, Cavenagh J, Yong K, Drayson MT, Owen R, Cook M, Cook G. The role of ixazomib as an augmented conditioning therapy in salvage autologous stem cell transplant (ASCT) and as a post-ASCT consolidation and maintenance strategy in patients with relapsed multiple myeloma (ACCoRd [UK-MRA Myeloma XII] trial): study protocol for a Phase III randomised controlled trial. Trials 2018; 19:169. [PMID: 29514706 PMCID: PMC5842589 DOI: 10.1186/s13063-018-2524-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple myeloma (MM) is a plasma cell tumour with an approximate annual incidence of 4500 in the UK. Therapeutic options for patients with MM have changed in the last decade with the arrival of proteasome inhibitors and immunomodulatory drugs. Despite these options, almost all patients will relapse post first-line autologous stem cell transplantation (ASCT). First relapse management (second-line treatment) has evolved in recent years with an expanding portfolio of novel agents, driving response rates influencing the durability of response. A second ASCT, as part of relapsed disease management (salvage ASCT), has been shown to prolong the progression-free survival and overall survival following a proteasome inhibitor-containing re-induction regimen, in the Cancer Research UK-funded National Cancer Research Institute Myeloma X (Intensive) study. It is now recommended that salvage ASCT be considered for suitable patients by the International Myeloma Working Group and the National Institute for Health and Care Excellence NG35 guidance. METHODS/DESIGN ACCoRd (Myeloma XII) is a UK-nationwide, individually randomised, multi-centre, multiple randomisation, open-label phase III trial with an initial single intervention registration phase aimed at relapsing MM patients who have received ASCT in first-line treatment. We will register 406 participants into the trial to allow 284 and 248 participants to be randomised at the first and second randomisations, respectively. All participants will receive re-induction therapy until maximal response (four to six cycles of ixazomib, thalidomide and dexamethasone). Participants who achieve at least stable disease will be randomised (1:1) to receive either ASCTCon, using high-dose melphalan, or ASCTAug, using high-dose melphalan with ixazomib. All participants achieving or maintaining a minimal response or better, following salvage ASCT, will undergo a second randomisation (1:1) to consolidation and maintenance or observation. Participants randomised to consolidation and maintenance will receive consolidation with two cycles of ixazomib, thalidomide and dexamethasone, and maintenance with ixazomib until disease progression. DISCUSSION The question of how best to maximise the durability of response to salvage ASCT warrants clinical investigation. Given the expanding scope of oral therapeutic agents, patient engagement with long-term maintenance strategies is a real opportunity. This study will provide evidence to better define post-relapse treatment in MM. TRIAL REGISTRATION ISRCTN, ISRCTN10038996 . Registered on 15 December 2016.
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Affiliation(s)
- Alina Striha
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - A. John Ashcroft
- Department of Haematology, Pinderfields General Hospital, Wakefield, UK
| | - Anna Hockaday
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David A. Cairns
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Karen Boardman
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Gwen Jacques
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Cathy Williams
- Centre for Clinical Haematology, Nottingham University Hospitals (City Campus), Nottingham, UK
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
| | - Jamie Cavenagh
- Department of Haematology, St Bartholomew’s Hospital, London, UK
| | - Kwee Yong
- Department of Haematology, University College Hospital, London, UK
| | - Mark T. Drayson
- Myeloma Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Roger Owen
- HMDS, St James’s University Hospital, Leeds, UK
| | - Mark Cook
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, UK
| | - Gordon Cook
- Leeds Institute of Cancer & Pathology, University of Leeds, St James’s University Hospital, Leeds, UK
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Brauer SG, Kuys SS, Paratz JD, Ada L. Improving physical activity after stroke via treadmill training and self management (IMPACT): a protocol for a randomised controlled trial. BMC Neurol 2018; 18:13. [PMID: 29382298 PMCID: PMC5791375 DOI: 10.1186/s12883-018-1015-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/03/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The level of physical activity undertaken by stroke survivors living in the community is generally low. The main objectives of the IMPACT trial are to determine, in individuals undergoing rehabilitation after stroke, if 8 weeks of high-intensity treadmill training embedded in self-management education (i) results in more physical activity than usual physiotherapy gait training and (ii) is more effective at increasing walking ability, cardiorespiratory fitness, self-efficacy, perception of physical activity, participation, and health-related quality of life as well as decreasing cardiovascular risk, and depression, at 8 and 26 weeks. METHODS A prospective, two-arm, parallel-group, randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis, will be conducted. 128 stroke survivors undergoing rehabilitation who are able to walk independently will be recruited and randomly allocated to either the experimental or control group, who will both undergo gait training for 30 min, three times a week for 8 weeks under the supervision of a physiotherapist. Outcomes will be measured at baseline (Week 0), on completion of the intervention (Week 8) and beyond the intervention (Week 26). This study has obtained ethical approval from the relevant Human Research Ethics Committees. DISCUSSION Improving stroke survivors' walking ability and cardiorespiratory fitness is likely to increase their levels of physical activity. Furthermore, if education in self-management results in sustained high levels of physical activity, this should result in improved participation and quality of life. TRIAL REGISTRATION This trial was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000744752 ) on 4th July, 2013.
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Affiliation(s)
- Sandra G. Brauer
- Discipline of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD Australia
| | - Suzanne S. Kuys
- School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Banyo, QLD Australia
| | - Jennifer D. Paratz
- School of Allied Health Sciences, Griffith University, Southport, QLD Australia
| | - Louise Ada
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, NSW Australia
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Talia AJ, Coetzee C, Tirosh O, Tran P. Comparison of outcome measures and complication rates following three different approaches for primary total hip arthroplasty: a pragmatic randomised controlled trial. Trials 2018; 19:13. [PMID: 29310681 PMCID: PMC5759198 DOI: 10.1186/s13063-017-2368-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 11/30/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Total hip arthroplasty is one of the most commonly performed surgical procedures worldwide. There are a number of surgical approaches for total hip arthroplasty and no high-level evidence supporting one approach over the other. Each approach has its unique benefits and drawbacks. This trial aims to directly compare the three most common surgical approaches for total hip arthroplasty. METHODS/DESIGN This is a single-centre study conducted at Western Health, Melbourne, Australia; a large metropolitan centre. It is a pragmatic, parallel three-arm, randomised controlled trial. Sample size will be 243 participants (81 in each group). Randomisation will be secure, web-based and managed by an independent statistician. Patients and research team will be blinded pre-operatively, but not post-operatively. Intervention will be either direct anterior, lateral or posterior approach for total hip arthroplasty, and the three arms will be directly compared. Participants will be aged over 18 years, able to provide informed consent and recruited from our outpatients. Patients who are having revision surgery or have indications for hip replacement other than osteoarthritis (i.e., fracture, malignancy, development dysplasia) will be excluded from the trial. The Oxford Hip Score will be determined for patients pre-operatively and 6 weeks, 6, 12 and 24 months post-operatively. The Oxford Hip Score at 24 months will be the primary outcome measure. Secondary outcome measures will be dislocation, infection, intraoperative and peri-prosthetic fracture rate, length of hospital stay and pain level, reported using a visual analogue scale. DISCUSSION Many studies have evaluated approaches for total hip arthroplasty and arthroplasty registries worldwide are now collecting this data. However no study to date has compared these three common approaches directly in a randomised fashion. No trial has used patient-reported outcome measures to evaluate success. This pragmatic study aims to identify differences in patient perception of total hip arthroplasty depending on surgical approach. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12617000272392 . Registered on 22 February 2017.
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Affiliation(s)
- Adrian J. Talia
- Department of Orthopaedics, Western Health, Gordon Street, Footscray, VIC 3011 Melbourne, Australia
| | - Cassandra Coetzee
- Department of Orthopaedics, Western Health, Gordon Street, Footscray, VIC 3011 Melbourne, Australia
| | - Oren Tirosh
- Department of Orthopaedics, Western Health, Gordon Street, Footscray, VIC 3011 Melbourne, Australia
| | - Phong Tran
- Department of Orthopaedics, Western Health, Gordon Street, Footscray, VIC 3011 Melbourne, Australia
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Solheim TS, Laird BJA, Balstad TR, Stene GB, Bye A, Johns N, Pettersen CH, Fallon M, Fayers P, Fearon K, Kaasa S. A randomized phase II feasibility trial of a multimodal intervention for the management of cachexia in lung and pancreatic cancer. J Cachexia Sarcopenia Muscle 2017; 8:778-788. [PMID: 28614627 PMCID: PMC5659068 DOI: 10.1002/jcsm.12201] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [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: 10/12/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cancer cachexia is a syndrome of weight loss (including muscle and fat), anorexia, and decreased physical function. It has been suggested that the optimal treatment for cachexia should be a multimodal intervention. The primary aim of this study was to examine the feasibility and safety of a multimodal intervention (n-3 polyunsaturated fatty acid nutritional supplements, exercise, and anti-inflammatory medication: celecoxib) for cancer cachexia in patients with incurable lung or pancreatic cancer, undergoing chemotherapy. METHODS Patients receiving two cycles of standard chemotherapy were randomized to either the multimodal cachexia intervention or standard care. Primary outcome measures were feasibility assessed by recruitment, attrition, and compliance with intervention (>50% of components in >50% of patients). Key secondary outcomes were change in weight, muscle mass, physical activity, safety, and survival. RESULTS Three hundred and ninety-nine were screened resulting in 46 patients recruited (11.5%). Twenty five patients were randomized to the treatment and 21 as controls. Forty-one completed the study (attrition rate 11%). Compliance to the individual components of the intervention was 76% for celecoxib, 60% for exercise, and 48% for nutritional supplements. As expected from the sample size, there was no statistically significant effect on physical activity or muscle mass. There were no intervention-related Serious Adverse Events and survival was similar between the groups. CONCLUSIONS A multimodal cachexia intervention is feasible and safe in patients with incurable lung or pancreatic cancer; however, compliance to nutritional supplements was suboptimal. A phase III study is now underway to assess fully the effect of the intervention.
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Affiliation(s)
- Tora S Solheim
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Barry J A Laird
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Trude Rakel Balstad
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Guro B Stene
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Asta Bye
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - Neil Johns
- Department of Surgery, School of Clinical Sciences, University of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Caroline H Pettersen
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Trondheim, Norway
| | - Marie Fallon
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Peter Fayers
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Kenneth Fearon
- Department of Surgery, School of Clinical Sciences, University of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Collett L, Howard DR, Munir T, McParland L, Oughton JB, Rawstron AC, Hockaday A, Dimbleby C, Phillips D, McMahon K, Hulme C, Allsup D, Bloor A, Hillmen P. Assessment of ibrutinib plus rituximab in front-line CLL (FLAIR trial): study protocol for a phase III randomised controlled trial. Trials 2017; 18:387. [PMID: 28830517 PMCID: PMC5568356 DOI: 10.1186/s13063-017-2138-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 02/24/2017] [Accepted: 08/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Treatment of chronic lymphocytic leukaemia (CLL) has seen a substantial improvement over the last few years. Combination immunochemotherapy, such as fludarabine, cyclophosphamide and rituximab (FCR), is now standard first-line therapy. However, the majority of patients relapse and require further therapy, and so new, effective, targeted therapies that improve remission rates, reduce relapses, and have fewer side effects, are required. The FLAIR trial will assess whether ibrutinib plus rituximab (IR) is superior to FCR in terms of progression-free survival (PFS). METHODS/DESIGN FLAIR is a phase III, multicentre, randomised, controlled, open, parallel-group trial in patients with previously untreated CLL. A total of 754 participants will be randomised on a 1:1 basis to receive standard therapy with FCR or IR. Participants randomised to FCR will receive a maximum of six 28-day treatment cycles. Participants randomised to IR will receive six 28-day cycles of rituximab, and ibrutinib taken daily for 6 years until minimal residual disease (MRD) negativity has been recorded for the same amount of time as it took to become MRD negative, or until disease progression. The primary endpoint is PFS according to the International Workshop on CLL (IWCLL) criteria. Secondary endpoints include: overall survival; proportion of participants with undetectable MRD; response to therapy by IWCLL criteria; safety and toxicity; health-related quality of life (QoL); and cost-effectiveness. DISCUSSION The trial aims to provide evidence for the future first-line treatment of CLL patients by assessing whether IR is superior to FCR in terms of PFS, and whether toxicity rates are favourable. TRIAL REGISTRATION ISRCTN01844152 . Registered on 8 August 2014, EudraCT number 2013-001944-76 . Registered on 26 April 2013.
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MESH Headings
- Adenine/analogs & derivatives
- Adolescent
- Adult
- Aged
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/economics
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cost-Benefit Analysis
- Disease Progression
- Disease-Free Survival
- Drug Costs
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/economics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Neoplasm, Residual
- Piperidines
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/economics
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrazoles/economics
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrimidines/economics
- Quality of Life
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Rituximab/economics
- Surveys and Questionnaires
- Time Factors
- Treatment Outcome
- United Kingdom
- Young Adult
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Affiliation(s)
- Laura Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Dena R. Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Talha Munir
- St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jamie B. Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Andy C. Rawstron
- Haematological Malignancy Diagnostic Service, St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Dimbleby
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David Allsup
- Hull York Medical School, Department of Haematology, Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK
| | - Adrian Bloor
- Department of Haematology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Peter Hillmen
- St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
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Lyttle MD, Gamble C, Messahel S, Hickey H, Iyer A, Woolfall K, Humphreys A, Bacon NEA, Roper L, Babl FE, Dalziel SR, Ryan M, Appleton RE; supported by Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI). Emergency treatment with levetiracetam or phenytoin in status epilepticus in children-the EcLiPSE study: study protocol for a randomised controlled trial. Trials 2017; 18:283. [PMID: 28629473 DOI: 10.1186/s13063-017-2010-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Convulsive status epilepticus (CSE) is the most common life-threatening neurological emergency in childhood. These children are also at risk of significant morbidity, with acute and chronic impact on the family and the health and social care systems. The current recommended first-choice, second-line treatment in children aged 6 months and above is intravenous phenytoin (fosphenytoin in the USA), although there is a lack of evidence for its use and it is associated with significant side effects. Emerging evidence suggests that intravenous levetiracetam may be effective as a second-line agent for CSE, and fewer adverse effects have been described. This trial therefore aims to determine whether intravenous phenytoin or levetiracetam is more effective, and safer, in treating childhood CSE. Methods/design This is a phase IV, multi-centre, parallel group, randomised controlled, open-label trial. Following treatment for CSE with first-line treatment, children with ongoing seizures are randomised to receive either phenytoin (20 mg/kg, maximum 2 g) or levetiracetam (40 mg/kg, maximum 2.5 g) intravenously. The primary outcome measure is the cessation of all visible signs of CSE as determined by the treating clinician. Secondary outcome measures include the need for further anti-seizure medications or rapid sequence induction for ongoing CSE, admission to critical care areas, and serious adverse reactions. Patients are recruited without prior consent, with deferred consent sought at an appropriate time for the family. The primary analysis will be by intention-to-treat. The primary outcome is a time to event outcome and a sample size of 140 participants in each group will have 80% power to detect an increase in CSE cessation rates from 60% to 75%. Our total sample size of 308 randomised and treated participants will allow for 10% loss to follow-up. Discussion This clinical trial will determine whether phenytoin or levetiracetam is more effective as an intravenous second-line agent for CSE, and provide evidence for management recommendations. In addition, this trial will also provide data on which of these therapies is safer in this setting. Trial registration ISRCTN identifier, ISRCTN22567894. Registered on 27 August 2015 EudraCT identifier, 2014-002188-13. Registered on 21 May 2014 NIHR HTA Grant: 12/127/134 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2010-8) contains supplementary material, which is available to authorized users.
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Paavola M, Malmivaara A, Taimela S, Kanto K, Järvinen TLN. Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT): a protocol for a randomised trial comparing arthroscopic subacromial decompression and diagnostic arthroscopy (placebo control), with an exercise therapy control, in the treatment of shoulder impingement syndrome. BMJ Open 2017; 7:e014087. [PMID: 28588109 PMCID: PMC5734212 DOI: 10.1136/bmjopen-2016-014087] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 02/02/2023] Open
Abstract
INTRODUCTION Arthroscopic subacromial decompression (ASD) is the most commonly performed surgical intervention for shoulder pain, yet evidence on its efficacy is limited. The rationale for the surgery rests on the tenet that symptom relief is achieved through decompression of the rotator cuff tendon passage. The primary objective of this superiority trial is to compare the efficacy of ASD versus diagnostic arthroscopy (DA) in patients with shoulder impingement syndrome (SIS), where DA differs only by the lack of subacromial decompression. A third group of supervised progressive exercise therapy (ET) will allow for pragmatic assessment of the relative benefits of surgical versus non-operative treatment strategies. METHODS AND ANALYSIS Finnish Subacromial Impingement Arthroscopy Controlled Trial is an ongoing multicentre, three-group randomised controlled study. We performed two-fold concealed allocation, first by randomising patients to surgical (ASD or DA) or conservative (ET) treatment in 2:1 ratio and then those allocated to surgery further to ASD or DA in 1:1 ratio. Our two primary outcomes are pain at rest and at arm activity, assessed using visual analogue scale (VAS). We will quantify the treatment effect as the difference between the groups in the change in the VAS scales with the associated 95% CI at 24 months. Our secondary outcomes are functional assessment (Constant score and Simple shoulder test), quality of life (15D and SF-36), patient satisfaction, proportions of responders and non-responders, reoperations/treatment conversions, all at 2 years post-randomisation, as well as adverse effects and complications. We recruited a total of 210 patients from three tertiary referral centres. We will conduct the primary analysis on the intention-to-treat basis. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board of the Pirkanmaa Hospital District and duly registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT00428870; Pre-results.
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Affiliation(s)
- Mika Paavola
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Malmivaara
- National Institute for Health and Welfare, Center for Health and Social Economics, Helsinki, Finland
| | - Simo Taimela
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kari Kanto
- Department of Orthopedics and Traumatology, Hatanpää City Hospital, Tampere, Finland
| | - Teppo LN Järvinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Nordenström J, Holmdahl G, Brandström P, Sixt R, Stokland E, Sillén U, Sjöström S. The Swedish infant high-grade reflux trial: Study presentation and vesicoureteral reflux outcome. J Pediatr Urol 2017; 13:130-138. [PMID: 27889221 DOI: 10.1016/j.jpurol.2016.08.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION High-grade vesicoureteral reflux (VUR) in infants is associated with congenital renal abnormalities, recurrent UTI, and bladder dysfunction. Endoscopic treatment (ET) is a well-established method in children with low to moderate reflux grades, but there is a lack of randomised controlled trials regarding the use of ET versus continuous antibiotic prophylaxis in infants with high-grade VUR. OBJECTIVE This study aimed to determine whether high-grade VUR in infants can be treated with endoscopic injection and whether ET is superior to antibiotic prophylaxis in the treatment of VUR. MATERIALS AND METHODS This prospective, randomised, controlled, multicentre, 1-year follow-up trial comprised 77 infants (55 boys, 22 girls) <8 months of age with VUR grade 4-5 (n = 30/n = 47). Of the infants, 52 (68%) had bilateral VUR. Thirty-nine were randomised to antibiotic prophylaxis and 38 to ET (with prophylaxis until resolution). Voiding cystourethrogram, ultrasound, renal scintigraphy, and free voiding observation were performed at study entry and after 1 year to evaluate VUR grade, and renal and bladder function. RESULTS VUR grade ≤2 was seen in 22 (59%) infants in the endoscopy group and eight (21%) in the prophylaxis group at follow-up (p = 0.0014). The success rate in the endoscopy group was 100% in unilateral grade 4, falling to 31% in bilateral grade 5 (p = 0.0094). Correspondingly, the results in the prophylaxis group were 40% in grade 4 down to 0% in bilateral grade 5 (p = 0.037) (Table). Logistic regression analyses identified ET, VUR grade 4, unilaterality, and low residual urine at baseline as positive predictors of VUR down-grading to ≤2 (area under ROC curve 0.88). In four patients with reflux resolution after one injection, dilating reflux recurred at the 1-year follow-up. One patient had a UTI possibly related to ET. In our material four patients required re-implantation, of whom one was obstructive after injection. DISCUSSION The opportunity to offer even small infants with high-grade VUR an alternative, minimally invasive treatment option is a great advance in paediatric urology. In this high-risk group, bilateral VUR grade 5 stands out with its poor bladder function and low chance of resolution. The recurrence rate of dilating VUR after successful ET is consistent with previous studies. The limitations are the relatively small number of patients and the short follow-up. CONCLUSION High-grade VUR in infants can be treated with injection therapy and the resolution rate is higher than that of prophylaxis treatment. The complication rate is low and VUR grade 4, unilaterality, and low residual urine are favourable for the resolution and down-grading of VUR.
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Affiliation(s)
- Josefin Nordenström
- Department of Paediatric Surgery, Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Gundela Holmdahl
- Department of Paediatric Surgery, Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Per Brandström
- Department of Paediatrics, Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Rune Sixt
- Department of Paediatric Clinical Physiology, Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Eira Stokland
- Department of Paediatric Radiology at the Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ulla Sillén
- Department of Paediatric Surgery, Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Sofia Sjöström
- Department of Paediatric Surgery, Paediatric Uronephrologic Centre, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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Sprowson AP, Jensen C, Chambers S, Parsons NR, Aradhyula NM, Carluke I, Inman D, Reed MR. The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip: The Fractured Hip Infection trial. Bone Joint J 2017; 98-B:1534-1541. [PMID: 27803231 PMCID: PMC5102031 DOI: 10.1302/0301-620x.98b11.34693] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/06/2016] [Indexed: 12/27/2022]
Abstract
Aims A fracture of the hip is the most common serious orthopaedic
injury, and surgical site infection (SSI) is one of the most significant
complications, resulting in increased mortality, prolonged hospital
stay and often the need for further surgery. Our aim was to determine
whether high dose dual antibiotic impregnated bone cement decreases the
rate of infection. Patients and Methods A quasi-randomised study of 848 patients with an intracapsular
fracture of the hip was conducted in one large teaching hospital
on two sites. All were treated with a hemiarthroplasty. A total
of 448 patients received low dose single-antibiotic impregnated
cement (control group) and 400 patients received high dose dual-antibiotic impregnated
cement (intervention group). The primary outcome measure was deep
SSI at one year after surgery. Results The rate of deep SSI was 3.5% in the control group and 1.1% in
the intervention group
(p = 0.041; logistic regression adjusting for age and gender). The
overall rate of non-infective surgical complications did not differ
between the two groups (unadjusted chi-squared test; p > 0.999). Conclusion The use of high dose dual-antibiotic impregnated cement in these
patients significantly reduces the rate of SSI compared with standard
low dose single antibiotic loaded bone cement. Cite this article: Bone Joint J 2016;98-B:1534–1541.
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Affiliation(s)
| | - C Jensen
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - S Chambers
- Northern Deanery Training Programme, Waterfront 4, Goldcrest Way, Newburn Riverside, Newcastle-upon-Tyne, NE15 8NY, UK
| | - N R Parsons
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - N M Aradhyula
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - I Carluke
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - D Inman
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, Rake Lane, North Shields, NE29 8NH, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
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Christersson A, Larsson S, Östlund B, Sandén B. Radiographic results after plaster cast fixation for 10 days versus 1 month in reduced distal radius fractures: a prospective randomised study. J Orthop Surg Res 2016; 11:145. [PMID: 27871284 PMCID: PMC5117580 DOI: 10.1186/s13018-016-0478-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/17/2016] [Indexed: 11/30/2022] Open
Abstract
Background The aim of this study was to examine whether reduced distal radius fractures can be treated with early mobilisation without affecting the radiographic results. Methods In a prospective randomised study, 109 patients (mean age 65.8 (range 50–92)) with moderately displaced distal radius fractures were treated with closed reduction and plaster cast fixation for about 10 days (range 8–13 days) followed by randomisation to one of two groups: early mobilisation (n = 54, active group) or continued plaster cast fixation for another 3 weeks (n = 55, control group). Results For three patients in the active group (6%), treatment proved unsuccessful because of severe displacement of the fracture (n = 2) or perceived instability (n = 1). From 10 days to 1 month, i.e. the only period when the treatment differed between the two groups, the active group displaced significantly more in dorsal angulation (4.5°, p < 0.001), radial angulation (2.0°, p < 0.001) and axial compression (0.5 mm, p = 0.01) compared with the control group. However, during the entire study period (i.e. from admission to 12 months), the active group displaced significantly more than the controls only in radial angulation (3.2°, p = 0.002) and axial compression (0.7 mm, p = 0.02). Conclusions Early mobilisation 10 days after reduction of moderately displaced distal radius fractures resulted in both an increased number of treatment failures and increased displacement in radial angulation and axial compression as compared with the control group. Mobilisation 10 days after reduction cannot be recommended for the routine treatment of reduced distal radius fractures. Trial registration ClinicalTrail.gov, NCT02798614. Retrospectively registered 16 June 2016.
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Affiliation(s)
- Albert Christersson
- Department of Surgical Science, Orthopaedics, Uppsala University, S-75185, Uppsala, Sweden.
| | - Sune Larsson
- Department of Surgical Science, Orthopaedics, Uppsala University, S-75185, Uppsala, Sweden
| | - Bengt Östlund
- Department of Orthopedics, Nyköping Hospital, S-61185, Nyköping, Sweden
| | - Bengt Sandén
- Department of Surgical Science, Orthopaedics, Uppsala University, S-75185, Uppsala, Sweden
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45
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Mearns H, Geldenhuys HD, Kagina BM, Musvosvi M, Little F, Ratangee F, Mahomed H, Hanekom WA, Hoff ST, Ruhwald M, Kromann I, Bang P, Hatherill M, Andersen P, Scriba TJ; THYB04 study group. H1:IC31 vaccination is safe and induces long-lived TNF-α +IL-2 +CD4 T cell responses in M. tuberculosis infected and uninfected adolescents: A randomized trial. Vaccine 2017; 35:132-41. [PMID: 27866772 DOI: 10.1016/j.vaccine.2016.11.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/20/2016] [Accepted: 11/07/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Control of the tuberculosis epidemic requires a novel vaccine that is effective in preventing tuberculosis in adolescents, a key target population for vaccination against TB. METHODS Healthy adolescents, stratified by M. tuberculosis-infection status, were enrolled into this observer-blinded phase II clinical trial of the protein-subunit vaccine candidate, H1:IC31, comprising a fusion protein (H1) of Ag85B and ESAT-6, formulated with the IC31 adjuvant. Local and systemic adverse events and induced T cell responses were measured after one or two administrations of either 15μg or 50μg of the H1 protein. RESULTS Two hundred and forty participants were recruited and followed up for 224days. No notable safety events were observed regardless of H1 dose or vaccination schedule. H1:IC31 vaccination induced antigen-specific CD4 T cells, co-expressing IFN-γ, TNF-α and/or IL-2. H1:IC31 vaccination of M.tb-uninfected individuals preferentially drove the emergence of Ag85B and ESAT-6 specific TNF-α+IL-2+CD4 T cells, while H1:IC31 vaccination of M.tb-infected individuals resulted in the expansion of Ag85B-specific but not ESAT-6-specific TNF-α+IL-2+CD4 T cells. CONCLUSIONS H1:IC31 was safe and immunogenic in uninfected and M.tb-infected adolescents. Two administrations of the 15μg H1:IC31 dose induced the greatest magnitude immune response, and was considered optimal (South African National Clinical Trials Register, DoH-27-0612-3947; Pan African Clinical Trial Registry, PACTR201403000464306).
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Buvik A, Bugge E, Knutsen G, Småbrekke A, Wilsgaard T. Quality of care for remote orthopaedic consultations using telemedicine: a randomised controlled trial. BMC Health Serv Res 2016; 16:483. [PMID: 27608768 PMCID: PMC5017045 DOI: 10.1186/s12913-016-1717-7] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 08/26/2016] [Indexed: 11/30/2022] Open
Abstract
Background Decentralised services using outreach clinics or modern technology are methods to reduce both patient transports and costs to the healthcare system. Telemedicine consultations via videoconference are one such modality. Before new technologies are implemented, it is important to investigate both the quality of care given and the economic impact from the use of this new technology. The aim of this clinical trial was to study the quality of planned remote orthopaedic consultations by help of videoconference. Method We performed a randomised controlled trial (RCT) with two parallel groups: video-assisted remote consultations at a regional medical centre (RMC) as an intervention versus standard consultation in the orthopaedic outpatient clinic at the University Hospital of North Norway (UNN) as a control. The participants were patients referred to or scheduled for a consultation at the orthopaedic outpatient clinic. The orthopaedic surgeons evaluated each consultation they performed by completing a questionnaire. The primary outcome measurement was the difference in the sum score calculated from this questionnaire, which was evaluated by the non-inferiority of the intervention group. The study design was based on the intention to treat principle. Ancillary analyses regarding complications, the number of consultations per patient, operations, patients who were referred again and the duration of consultations were performed. Results Four-hundred patients were web-based randomised. Of these, 199 (98 %) underwent remote consultation and 190 (95 %) underwent standard consultation. The primary outcome, the sum score of the specialist evaluation, was significantly lower (i.e. ‘better’) at UNN compared to RMC (1.72 versus 1.82, p = 0.0030). The 90 % confidence interval (CI) for the difference in score (0.05, 0.17) was within the non-inferiority margin. The orthopaedic surgeons involved evaluated 98 % of the video-assisted consultations as ‘good’ or ‘very good’. In the ancillary analyses, there was no significant difference between the two groups. Conclusions This study supports the argument that it is safe to offer video-assisted consultations for selected orthopaedic patients. We did not find any serious events related to the mode of consultation. Further assessments of the economic aspects and patient satisfaction are needed before we can recommend its wider application. Trial registration ClinicalTrials.gov identifier: NCT00616837 Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1717-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Astrid Buvik
- Department of Orthopaedic Surgery, University Hospital of North Norway, P.O. Box 4, N-9038, Tromsø, Norway.
| | - Einar Bugge
- Centre for Clinical Research and Education, University Hospital of North Norway, P.O. Box 20, N-9038, Tromsø, Norway
| | - Gunnar Knutsen
- Department of Orthopaedic Surgery, University Hospital of North Norway, P.O. Box 4, N-9038, Tromsø, Norway
| | - Arvid Småbrekke
- Department of Orthopaedic Surgery, University Hospital of North Norway, P.O. Box 4, N-9038, Tromsø, Norway
| | - Tom Wilsgaard
- Centre for Clinical Research and Education, University Hospital of North Norway, P.O. Box 20, N-9038, Tromsø, Norway.,Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, 9037, Tromsø, Norway
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47
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Buvik A, Bugge E, Knutsen G, Småbrekke A, Wilsgaard T. Quality of care for remote orthopaedic consultations using telemedicine: a randomised controlled trial. BMC Health Serv Res 2016. [PMID: 27608768 DOI: 10.1186/s12913-016-1717-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decentralised services using outreach clinics or modern technology are methods to reduce both patient transports and costs to the healthcare system. Telemedicine consultations via videoconference are one such modality. Before new technologies are implemented, it is important to investigate both the quality of care given and the economic impact from the use of this new technology. The aim of this clinical trial was to study the quality of planned remote orthopaedic consultations by help of videoconference. METHOD We performed a randomised controlled trial (RCT) with two parallel groups: video-assisted remote consultations at a regional medical centre (RMC) as an intervention versus standard consultation in the orthopaedic outpatient clinic at the University Hospital of North Norway (UNN) as a control. The participants were patients referred to or scheduled for a consultation at the orthopaedic outpatient clinic. The orthopaedic surgeons evaluated each consultation they performed by completing a questionnaire. The primary outcome measurement was the difference in the sum score calculated from this questionnaire, which was evaluated by the non-inferiority of the intervention group. The study design was based on the intention to treat principle. Ancillary analyses regarding complications, the number of consultations per patient, operations, patients who were referred again and the duration of consultations were performed. RESULTS Four-hundred patients were web-based randomised. Of these, 199 (98 %) underwent remote consultation and 190 (95 %) underwent standard consultation. The primary outcome, the sum score of the specialist evaluation, was significantly lower (i.e. 'better') at UNN compared to RMC (1.72 versus 1.82, p = 0.0030). The 90 % confidence interval (CI) for the difference in score (0.05, 0.17) was within the non-inferiority margin. The orthopaedic surgeons involved evaluated 98 % of the video-assisted consultations as 'good' or 'very good'. In the ancillary analyses, there was no significant difference between the two groups. CONCLUSIONS This study supports the argument that it is safe to offer video-assisted consultations for selected orthopaedic patients. We did not find any serious events related to the mode of consultation. Further assessments of the economic aspects and patient satisfaction are needed before we can recommend its wider application. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00616837.
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Affiliation(s)
- Astrid Buvik
- Department of Orthopaedic Surgery, University Hospital of North Norway, P.O. Box 4, N-9038, Tromsø, Norway.
| | - Einar Bugge
- Centre for Clinical Research and Education, University Hospital of North Norway, P.O. Box 20, N-9038, Tromsø, Norway
| | - Gunnar Knutsen
- Department of Orthopaedic Surgery, University Hospital of North Norway, P.O. Box 4, N-9038, Tromsø, Norway
| | - Arvid Småbrekke
- Department of Orthopaedic Surgery, University Hospital of North Norway, P.O. Box 4, N-9038, Tromsø, Norway
| | - Tom Wilsgaard
- Centre for Clinical Research and Education, University Hospital of North Norway, P.O. Box 20, N-9038, Tromsø, Norway.,Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, 9037, Tromsø, Norway
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Hardy P, Bell JL, Brocklehurst P. Evaluation of the effects of an offer of a monetary incentive on the rate of questionnaire return during follow-up of a clinical trial: a randomised study within a trial. BMC Med Res Methodol 2016; 16:82. [PMID: 27421268 PMCID: PMC4946239 DOI: 10.1186/s12874-016-0180-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 03/31/2016] [Accepted: 06/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A systematic review on the use of incentives to promote questionnaire return in clinical trials suggest they are effective, but not all studies have sufficient funds to use them. Promising an incentive once data are returned can reduce the cost-burden of this approach, with possible further cost-savings if the offer were restricted to reminder letters only. This study aimed to evaluate the effect of promising a monetary incentive at first mailout versus a promise on reminder letters only. METHODS This was a randomised Study Within A Trial (SWAT) nested within BUMPES, a multicentre randomised controlled trial of maternal position in the late stage of labour in women with an epidural. The follow-up questionnaire asked for information on the women's health, wellbeing and health service use one year following the birth of their baby. Women who consented to be contacted were randomised to a promise of a monetary incentive at first mailout or a promise on reminder letters only. Women were given an option of completing the questionnaire on paper or on online. The incentive was posted out on receipt of a completed questionnaire. The primary outcome was the overall return rate, and secondary outcomes were the return rate without any chasing from the study office, and the total cost of the vouchers. RESULTS A total of 1,029 women were randomised, 508 to the first mailout group and 518 to the reminder group. There was no evidence to suggest a difference between groups in the overall return rate (adjusted RR 1.03 (95 % CI 0.96 to 1.11), however the proportion returned without chasing was higher in the first mailout group (adjusted RR 1.22, 95 % CI 1.07 to 1.39). The total cost of the vouchers per participant was higher in the first mailout group (mean difference £4.56, 95 % CI £4.02 to £5.11). CONCLUSIONS Offering a monetary incentive when a reminder is required could be cost-effective depending on the sample size of the study and the resources available to administer the reminder letters. TRIAL REGISTRATION The BUMPES Trial is registered with Current Controlled Trials: ISRCTN35706297 , 26(th) August 2009.
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Affiliation(s)
- Pollyanna Hardy
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit CTU, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Jennifer L Bell
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit CTU, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
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Ring H, Gilbert N, Hook R, Platt A, Smith C, Irvine F, Donaldson C, Jones E, Kelly J, Mander A, Murphy C, Pennington M, Pullen A, Redley M, Rowe S, Wason J. Improving outcomes in adults with epilepsy and intellectual disability (EpAID) using a nurse-led intervention: study protocol for a cluster randomised controlled trial. Trials 2016; 17:297. [PMID: 27342377 PMCID: PMC4919880 DOI: 10.1186/s13063-016-1429-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 05/11/2016] [Indexed: 11/26/2022] Open
Abstract
Background In adults with intellectual disability (ID) and epilepsy there are suggestions that improvements in management may follow introduction of epilepsy nurse-led care. However, this has not been tested in a definitive clinical trial and results cannot be generalised from general population studies as epilepsy tends to be more severe and to involve additional clinical comorbidities in adults with ID. This trial investigates whether nurses with expertise in epilepsy and ID, working proactively to a clinically defined role, can improve clinical and quality of life outcomes in the management of epilepsy within this population, compared to treatment as usual. The trial also aims to establish whether any perceived benefits represent good value for money. Methods/design The EpAID clinical trial is a two-arm cluster randomised controlled trial of nurse-led epilepsy management versus treatment as usual. This trial aims to obtain follow-up data from 320 participants with ID and drug-resistant epilepsy. Participants are randomly assigned either to a ‘treatment as usual’ control or a ‘defined epilepsy nurse role’ active arm, according to the cluster site at which they are treated. The active intervention utilises the recently developed Learning Disability Epilepsy Specialist Nurse Competency Framework for adults with ID. Participants undergo 4 weeks of baseline data collection, followed by a minimum of 20 weeks intervention (novel treatment or treatment as usual), followed by 4 weeks of follow-up data collection. The primary outcome is seizure severity, including associated injuries and the level of distress manifest by the patient in the preceding 4 weeks. Secondary outcomes include cost-utility analysis, carer strain, seizure frequency and side effects. Descriptive measures include demographic and clinical descriptors of participants and clinical services in which they receive their epilepsy management. Qualitative study of clinical interactions and semi-structured interviews with clinicians and participants’ carers are also undertaken. Discussion The EpAID clinical trial is the first cluster randomised controlled trial to test possible benefits of a nurse-led intervention in adults with epilepsy and ID. This research will have important implications for ID and epilepsy services. The challenges of undertaking such a trial in this population, and the approaches to meeting these are discussed. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN96895428 version 1.1. Registered on 26 March 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1429-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Howard Ring
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK. .,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK. .,NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England, Cambridge, UK.
| | - Nakita Gilbert
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK
| | - Roxanne Hook
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK
| | - Adam Platt
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK
| | - Christopher Smith
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK
| | - Fiona Irvine
- School of Health and Population Science, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, UK
| | - Elizabeth Jones
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK.,NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England, Cambridge, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, PO64 Institute of Psychiatry, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Adrian Mander
- MRC Biostatistics Unit Hub for Trials Methodology Research, Institute of Public Health, Robinson Way, Cambridge, CB2 0SR, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, PO64 Institute of Psychiatry, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Mark Pennington
- Kings Health Economics, PO24, David Goldberg Centre, Institute of Psychiatry Psychology and Neuroscience, Kings College London, De Crespigny Park, London, SE5 8AF, UK
| | - Angela Pullen
- Epilepsy Action, New Antsey House, Gate Way Drive, Yeadon, Leeds, LS19 7XY, UK.,NHS Leeds West Clinical Commissioning Group, Suites 2-4, Wira House, Wira Business Park, Leeds, LS16 6EB, UK
| | - Marcus Redley
- Department of Psychiatry, University of Cambridge, Douglas House, 18d Trumpington Road, Cambridge, CB2 8AH, UK.,NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England, Cambridge, UK
| | - Simon Rowe
- NHS Wakefield Clinical Commissioning Group, White Rose House, West Parade, Wakefield, West Yorkshire, WF1 1LT, UK
| | - James Wason
- King's Clinical Trials Unit, PO64 Institute of Psychiatry, King's College London, De Crespigny Park, London, SE5 8AF, UK
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José A, Dal Corso S. Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial. J Physiother 2016; 62:96-102. [PMID: 26996093 DOI: 10.1016/j.jphys.2016.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 02/09/2016] [Accepted: 02/17/2016] [Indexed: 12/01/2022] Open
Abstract
QUESTION Among people who are hospitalised for community-acquired pneumonia, does an inpatient exercise-based rehabilitation program improve functional outcomes, symptoms, quality of life and length of hospital stay more than a respiratory physiotherapy regimen? DESIGN Randomised trial with concealed allocation, intention-to-treat analysis and blinding of some outcomes. PARTICIPANTS Forty-nine adults hospitalised for community-acquired pneumonia. INTERVENTION The experimental group (n=32) underwent a physical training program that included warm-up, stretching, peripheral muscle strength training and walking at a controlled speed for 15 minutes. The control group (n=17) underwent a respiratory physiotherapy regimen that included percussion, vibrocompression, respiratory exercises and free walking. The intervention regimens lasted 8 days. OUTCOME MEASURES The primary outcome was the Glittre Activities of Daily Living test, which assesses the time taken to complete a series of functional tasks (eg, rising from a chair, walking, stairs, lifting and bending). Secondary outcomes were distance walked in the incremental shuttle walk test, peripheral muscle strength, quality of life, dyspnoea, lung function, C-reactive protein and length of hospital stay. Measures were taken 1 day before and 1 day after the intervention period. RESULTS There was greater improvement in the experimental group than in the control group on the Glittre Activities of Daily Living test (mean between-group difference 39 seconds, 95% CI 20 to 59) and the incremental shuttle walk test (mean between-group difference 130 m, 95% CI 77 to 182). There were also significantly greater improvements in quality of life, dyspnoea and peripheral muscle strength in the experimental group than in the control group. There were no between-group differences in lung function, C-reactive protein or length of hospital stay. CONCLUSION The improvement in functional outcomes after an inpatient rehabilitation program was greater than the improvement after standard respiratory physiotherapy. The exercise training program led to greater benefits in functional capacity, peripheral muscle strength, dyspnoea and quality of life. REGISTRATION ClinicalTrials.gov, NCT02103400.
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Affiliation(s)
- Anderson José
- Post-graduate Program in Rehabilitation Sciences, Universidade Nove de Julho, São Paulo, Brazil
| | - Simone Dal Corso
- Post-graduate Program in Rehabilitation Sciences, Universidade Nove de Julho, São Paulo, Brazil
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