Design and Methodology of a Multi-Centre Clinical Trial of Low Dose Laser Cycloplasty for the Treatment of Malignant Glaucoma in China

PURPOSE

To summarize the design and methodology of a trial designed to evaluate the efficacy and safety of low dose laser cycloplasty (LCP) in treating malignant glaucoma.

METHODS

Prospective, multicentre, non-controlled clinical trial. Subjects were recruited from eight ophthalmic centers in China. The target sample size was 34. Patients aged >18 years with a clinical diagnosis of malignant glaucoma inadequately controlled on medical therapy or malignant glaucoma recurrence after topical cycloplegics withdrawal were enrolled. All patients underwent LCP under retrobulbar anesthesia or sub-Tenon anesthesia. LCP is a treatment adopting few laser points (1100-2000 mW energy, 2000 milliseconds duration) that cauterizes and remodels the ciliary body over two clock hour-positions, which may relieve the ciliary ring block. Follow-up is planned for a period of 12 months. The primary outcome is the resolution of malignant glaucoma which is defined as central anterior chamber deepening after LCP.

CONCLUSION

The Malignant Glaucoma Treatment trial (MGTT) will be the first prospective trial providing evidence of a treatment for malignant glaucoma. It intends to provide clinicians an optional, easy and convenient treatment for malignant glaucoma patients. Detailed morphological and biometric information collected during the study period will also help provide experience for the outcomes of malignant glaucoma.

TRIAL REGISTRATION NUMBER

ChiCTR1800017960.

Non-Pharmaceutical Interventions for Self-Regulatory Failures in Adolescents Suffering from Externalizing Symptoms: A Scoping Review

Introduction: Deficits of self-regulation (SR) are a hallmark of externalizing (EXT: offending or aggressive behaviors) symptoms in adolescence. Objectives: This scoping review aims (1) to map non-pharmaceutical interventions targeting SR processes to reduce EXT symptoms in adolescents and (2) to identify research gaps, both of which will provide recommendations for future studies. Methods: Systematic searches were carried out in eight bibliographic databases up to March 2021, combining the following concepts: self-regulation, externalizing symptoms, adolescents, and non-pharmaceutical interventions. Results: We identified 239 studies, including 24,180 youths, mainly from North America, which described a plethora of non-pharmaceutical interventions targeting SR to alleviate EXT symptoms in adolescents (10–18 years of age). The majority of studies (about 70%, k = 162) represent samples with interventions exposed to “selective” or “indicated” prevention. Curriculum-based (i.e., multiple approaches targeting several domains such as emotion, cognition, and social) interventions (31.4%) were the most common type of intervention. Moreover, studies on cognitive-based interventions, mind-based interventions, and emotional-based interventions have increased over the last decades. Network analyses allowed us to identify several hubs between curriculum-based interventions, cognitive SR processes, as well as aggressiveness, conduct problems, and irritability/anger dysregulation. In addition, we identified gaps of studies concerning the physiological SR processes and on some types of interventions (i.e., body-based interventions and externally mediated interventions) or, more specifically, on promising tools, such as biofeedback, neurofeedback, as well as programs targeting neuropsychological processes (e.g., cognitive remediation). Conclusions: This scoping review stresses the plethora of interventions, identified hubs, and emerging fields, as well as some gaps in the literature, which together may orient future studies.

Successful strategies for including adults with intellectual disabilities in research studies that use interpretative phenomenological analysis

BACKGROUND

Adults with intellectual disabilities are not often asked to participate in health research. This may be because researchers perceive them as unable to participate meaningfully with or without significant support and anticipate difficulty in obtaining ethical approval because of issues concerning consent and mental capacity. This means that the voices of adults with intellectual disabilities are often missing from health research and their experiences and views are unexplored.

AIM

To share successful strategies for accessing, recruiting and collecting data from a purposive sample of adults with intellectual disabilities from a study that used interpretative phenomenological analysis (IPA).

DISCUSSION

IPA is a person-centred, flexible and creative approach to research. Meaningful collaboration with people with intellectual disabilities, their families, carers, advocacy group managers, specialists in intellectual disability services and research supervisors was vital to the success of the study. The authors share practical strategies for including people with intellectual disabilities, from the perspective of a novice researcher who is an outsider to the field of intellectual disability.

CONCLUSION

It is important to include people with intellectual disabilities in healthcare research. This article presents a framework to support researchers outside the specialist field of intellectual disabilities in achieving this.

IMPLICATIONS FOR PRACTICE

Personal views and perceptions of healthcare are important if health services are to meet individual needs. Adults with intellectual disabilities often receive poor healthcare and have poorer outcomes. This will be perpetuated without their input into research. People with intellectual disabilities can make valuable contributions to the evidence base.

Study Designs in Clinical Research

Background: The quality of scientific literature is judged by study design, validity, and applicability to unique patient populations. Methods: We searched the available literature to explore the hierarchy of evidence, explain research fundamentals such as sample size calculation, and discuss common study designs employed in surgical research and the interpretation of trial designs. Results: Each unique study design has restraints created by some degree of systematic errors and bias. This article provides definitions for the scientific boundaries of case control, retrospective, before-and-after, prospective observational, randomized controlled designs, and meta-analyses. Conclusion: Critical thinking and appraisal of the literature is a skill that requires lifelong training and practice. Clinical research education and design need to garner more attention in the medical community.

Study Designs to Assess Real-World Interventions to Prevent COVID-19

Background: In the face of the novel virus SARS-CoV-2, scientists and the public are eager for evidence about what measures are effective at slowing its spread and preventing morbidity and mortality. Other than mathematical modeling, studies thus far evaluating public health and behavioral interventions at scale have largely been observational and ecologic, focusing on aggregate summaries. Conclusions from these studies are susceptible to bias from threats to validity such as unmeasured confounding, concurrent policy changes, and trends over time. We offer recommendations on how to strengthen frequently applied study designs which have been used to understand the impact of interventions to reduce the spread of COVID-19, and suggest implementation-focused, pragmatic designs that, moving forward, could be used to build a robust evidence base for public health practice. Methods: We conducted a literature search of studies that evaluated the effectiveness of non-pharmaceutical interventions and policies to reduce spread, morbidity, and mortality of COVID-19. Our targeted review of the literature aimed to explore strengths and weaknesses of implemented studies, provide recommendations for improvement, and explore alternative real-world study design methods to enhance evidence-based decision-making. Results:Study designs such as pre/post, interrupted time series, and difference-in-differences have been used to evaluate policy effects at the state or country level of a range of interventions, such as shelter-in-place, face mask mandates, and school closures. Key challenges with these designs include the difficulty of disentangling the effects of contemporaneous changes in policy and correctly modeling infectious disease dynamics. Pragmatic study designs such as the SMART (Sequential, Multiple-Assignment Randomized Trial), stepped wedge, and preference designs could be used to evaluate community re-openings such as schools, and other policy changes. Conclusions: As the epidemic progresses, we need to move from post-hoc analyses of available data (appropriate for the beginning of the pandemic) to proactive evaluation to ensure the most rigorous approaches possible to evaluate the impact of COVID-19 prevention interventions. Pragmatic study designs, while requiring initial planning and community buy-in, could offer more robust evidence on what is effective and for whom to combat the global pandemic we face and future policy decisions.

The effects of acute stress on eyewitness memory: an integrative review for eyewitness researchers

The eyewitness and fundamental memory research fields have investigated the effects of acute stress at encoding on memory performance for decades yet results often demonstrate contrasting conclusions. In this review, we first summarise findings on the effects of acute encoding stress on memory performance and discuss how these research fields often come to these diverging findings regarding the effects of encoding stress on memory performance. Next, we critically evaluate methodological choices that underpin these discrepancies, emphasising the strengths and limitations of different stress-memory experiments. Specifically, we elaborate on choice of stressors and stimuli, stress manipulation checks, stressor timing, and the interval between encoding and retrieval and discuss how methodological shortcomings in both the eyewitness and fundamental memory fields have limited our understanding of how encoding stress may affect eyewitness memory performance. Finally, we propose several recommendations for researchers interested in this topic, such as confirming stress inductions with physiological measures, implementing sufficient retrieval intervals to isolate the memory phase of interest and using ecologically valid memory paradigms. We conclude that the best progress can be made if researchers are responsive to the methodologies and findings reported in other research fields and encourage collaborations between the different disciplines.

Pharmacokinetic bioequivalence, safety, and immunogenicity of GB222, a bevacizumab biosimilar candidate, and bevacizumab in Chinese healthy males: a randomized clinical trial

BACKGROUND

This study was conducted to compare the similarity of the pharmacokinetics (PKs), safety, and immunogenicity of GB222, a potential bevacizumab biosimilar, to that of reference bevacizumab in Chinese healthy males.

RESEARCH DESIGN AND METHODS

This was a randomized, double-blind, single-dose, parallel-group clinical trial performed in 84 Chinese healthy males, who were randomly assigned to receive a single infusion dose of 1 mg/kg GB222 or bevacizumab with an 84-days follow-up. The primary endpoint was the area under the plasma concentration-time curve (AUC) from zero to the last quantifiable concentration at time t (AUC_0-t). The second endpoints were the safety and immunogenicity evaluation. The PK bioequivalence was verified by the 90% confidence intervals (CIs) of the geometrical mean (GM) ratio for AUC_0-t falling within the bioequivalence margin, 80-125%.

RESULTS

The PK profiles of GB222 and bevacizumab were comparable. The 90% CIs of GM ratio of GB222 to bevacizumab for AUC_0-t was within the pre-specified bioequivalence margin. The most common treatment-related adverse event was sinus bradycardia. Seventeen subjects (20.2%) tested positive for anti-drug antibodies (ADAs).

CONCLUSION

GB222 was found to be comparable to bevacizumab in terms of PKs, safety, and immunogenicity for Chinese healthy males.

TRIAL REGISTRATION

ChiCTR-IIR-17,011,143.

Bias of time-varying exposure effects due to time-varying covariate measurement strategies

Purpose

In studies of effects of time‐varying drug exposures, adequate adjustment for time‐varying covariates is often necessary to properly control for confounding. However, the granularity of the available covariate data may not be sufficiently fine, for example when covariates are measured for participants only when their exposure levels change.

Methods

To illustrate the impact of choices regarding the frequency of measuring time‐varying covariates, we simulated data for a large target trial and for large observational studies, varying in covariate measurement design. Covariates were measured never, on a fixed‐interval basis, or each time the exposure level switched. For the analysis, it was assumed that covariates remain constant in periods of no measurement. Cumulative survival probabilities for continuous exposure and non‐exposure were estimated using inverse probability weighting to adjust for time‐varying confounding, with special emphasis on the difference between 5‐year event risks.

Results

With monthly covariate measurements, estimates based on observational data coincided with trial‐based estimates, with 5‐year risk differences being zero. Without measurement of baseline or post‐baseline covariates, this risk difference was estimated to be 49% based on the available observational data. With measurements on a fixed‐interval basis only, 5‐year risk differences deviated from the null, to 29% for 6‐monthly measurements, and with magnitude increasing up to 35% as the interval length increased. Risk difference estimates diverged from the null to as low as −18% when covariates were measured depending on exposure level switching.

Conclusion

Our simulations highlight the need for careful consideration of time‐varying covariates in designing studies on time‐varying exposures. We caution against implementing designs with long intervals between measurements. The maximum length required will depend on the rates at which treatments and covariates change, with higher rates requiring shorter measurement intervals.

Long-term Weight Changes and Risk of Rheumatoid Arthritis Among Women in a Prospective Cohort: A Marginal Structural Model Approach

OBJECTIVE

To examine the association of long-term weight change with rheumatoid arthritis (RA) risk in a large prospective cohort study.

METHODS

The Nurses' Health Study (NHS) II started in 1989 (baseline); after exclusions, we studied 108,505 women 25-42 years old without RA. Incident RA was reported by participant and confirmed by medical record review. Body weight was reported biennially through 2015. We investigated two time-varying exposures: weight changes from baseline and from age 18; change was divided into 5 categories. We used a marginal structural model (MSM) approach to account for time-varying weight change and covariates.

RESULTS

Over 2,583,266 person-years, with a median follow-up time of 25.3 years, 541 women developed RA. Compared to women with stable weight from baseline, weight change was significantly associated with increased RA risk [weight gain 2-<10 kg: RR = 1.98 (95% CI 1.38, 2.85); 10-<20 kg: RR = 3.28 (95% CI 2.20, 4.89); ≥20 kg: RR = 3.81 (95% CI 2.39, 6.07); and weight loss >2 kg: RR = 2.05 (95% CI 1.28, 3.28)]. Weight gain of 10 kg or more from age 18 compared with stable weight was also associated with increased RA risk [10-< 20 kg: RR = 2.12 (95% CI 1.37, 3.27), ≥20 kg: RR = 2.31 (95% CI 1.50, 3.56)]. Consistent findings were observed for seropositive and seronegative RA.

CONCLUSION

Long-term weight gain was strongly associated with increased RA risk in women, with weight gain of ≥ 20 kg associated with more than a three-fold increased RA risk. Maintenance of healthy weight may be a strategy to prevent or delay RA.

Invited Commentary: The Prevalent New-User Design in Pharmacoepidemiology-Challenges and Opportunities

The prevalent new-user design includes a broader study population than the traditional new-user approach that is frequently used in pharmacoepidemiologic research. In an article appearing in this issue (Am J Epidemiol. 2021;190(7):1341-1348), Webster-Clark et al. describe the treatment initiator types included in the prevalent new-user design and contrast the causal questions assessed using a prevalent new-user design versus a new-user design. They further applied a series of simulation studies showing the importance of accounting for treatment history in addition to time since initiation of the comparator in the prevalent new-user design. In this commentary, we put their findings in the broader context with a discussion of the strengths and limitations of the prevalent new-user design and settings where it would be most useful. The prevalent new-user design and new-user design both address unique questions of clinical and public health importance. Real-world evidence generated by pharmacoepidemiologic research is increasingly being used by regulators and other knowledge users to inform their decision-making. Understanding the causal questions addressed by different designs is crucial in this process; the study by Webster-Clark et al. represents an important step in addressing this issue.

Guidance and conceptual tools to inform the design, selection and evaluation of research capacity strengthening interventions

This practice note presents four conceptual tools intended to support the design, selection and evaluation of research capacity strengthening (RCS) programmes in low-income and middle-income country settings. The tools may be used by a wide range of RCS stakeholders, including funders, implementing parties and programme evaluators, to guide decision-making in lieu of largely as yet unavailable empirical evidence. The first conceptual tool guides decision-making regarding RCS intervention design, focusing specifically on the combination and integration of potential intervention activities. The second conceptual tool provides a framework for assessing the implementation challenges of potential RCS interventions in terms of: (1) the overall cost of implementing the proposed intervention in a given context; (2) the length of time required to complete full implementation of the proposed intervention in a given context and (3) the level of control the implementing partners would have over the proposed intervention in a given context. The third conceptual tool provides a means to consider the anticipated impact of potential RCS interventions in order to inform selection decisions (ie, which out of a number of potential RCS intervention options may be most impactful in a given setting given the intervention design and implementation challenges). The fourth and final tool is designed to support the evaluation of a collective RCS effort, whether that be multiple RCS interventions delivered within the context of a single or continuous programme or multiple RCS programmes delivered in a common setting.

Managing biological variation data: modern approaches for study design and clinical application

For more than one half-century, variability observed in clinical test result measurements has been ascribed to three major independent factors: (i) pre-analytical variation, occurring at sample collection and processing steps; (ii) analytical variation of the test method for which measurements are taken, and; (iii) biological variation (BV). Appreciation of this last source of variability is the major goal of this review article. Several recent advances have been made to generate, collate, and utilize BV data of biomarker tests within the clinical laboratory setting. Consideration of both prospective and retrospective study designs will be addressed. The prospective/direct study design will be described in accordance with recent recommendations discussed in the framework of a newly-developed system of checklist items. Potential value of retrospective/indirect study design, modeled on data mining from cohort studies or pathology laboratory information systems (LIS), offers an alternative approach to obtain BV estimates for clinical biomarkers. Moreover, updates to BV databases have made these data more current and widely accessible. Principal aims of this review are to provide the clinical laboratory scientist with a historical framework of BV concepts, to highlight useful applications of BV data within the clinical laboratory environment, and to discuss key terms and concepts related to statistical treatment of BV data.

Constructing a middle-range theory to explain the uptake of hepatitis C tests in prison

BACKGROUND

Realist evaluation is increasingly used in healthcare research, and theories can provide plausible explanations of why interventions work or do not work in certain circumstances such as the effect of the opt-out hepatitis C virus (HCV) testing policy in English prisons.

AIM

To present the process of constructing the middle-range theories (MRTs) developed as part of an evaluation of hepatitis C test uptake in an English prison as a resource for researchers using realist evaluation.

DISCUSSION

MRTs are propositions that can explain a particular behaviour or outcome. In this evaluation, the MRTs emerged from a realist evaluation, a theory-driven approach for understanding what interventions work, in what circumstances and how. The mixed-methods data collected during the realist evaluation and the sociological theory of prisonisation were used to create the MRTs. Combining prisonisation with the qualitative data illustrates how healthcare interventions may be viewed by people in prison who may have adopted either the 'deprivation' or 'importation' processes of adaptation to cope with their incarceration. Their views may affect the acceptance of HCV tests.

CONCLUSION

The development of MRTs is a creative and iterative process, requiring an in-depth understanding of the data collected and the subject area. MRTs permit us to see relationships among phenomena that might otherwise seem disconnected, thereby aiding the development of more efficacious interventions.

IMPLICATIONS FOR PRACTICE

The MRT developed presents an evidence base for selecting interventions to increase the uptake of HCV tests in prisons. This paper explains how a MRT was developed and how HCV test uptake in prisons can be explained using a sociological theory.

Methods for capturing patient experience and satisfaction in healthcare services

Patient experience in healthcare has long been recognised in the UK and internationally as a crucial benchmark for assessing quality of care in healthcare settings. It is increasingly becoming part of a nurse's role to conduct, analyse and present the findings of patient satisfaction audits and research projects, and to implement changes to services based on the data collected. To undertake these audits and projects effectively, nurses require knowledge of how to use various data collection methods and research tools, determine their validity and reliability, and minimise bias. This article provides information about these areas, with the aim of assisting nurses in designing and implementing patient satisfaction audits and research projects in their clinical area, which can subsequently be used to improve patient experience.

Design and Rationale of HiLo: A Pragmatic, Randomized Trial of Phosphate Management for Patients Receiving Maintenance Hemodialysis

RATIONALE & OBJECTIVE

Hyperphosphatemia is a risk factor for poor clinical outcomes in patients with kidney failure receiving maintenance dialysis. Opinion-based clinical practice guidelines recommend the use of phosphate binders and dietary phosphate restriction to lower serum phosphate levels toward the normal range in patients receiving maintenance dialysis, but the benefits of these approaches and the optimal serum phosphate target have not been tested in randomized trials. It is also unknown if aggressive treatment that achieves unnecessarily low serum phosphate levels worsens outcomes.

STUDY DESIGN

Multicenter, pragmatic, cluster-randomized clinical trial.

SETTING & PARTICIPANTS

HiLo will randomize 80-120 dialysis facilities operated by DaVita Inc and the University of Utah to enroll 4,400 patients undergoing 3-times-weekly, in-center hemodialysis.

INTERVENTION

Phosphate binder prescriptions and dietary recommendations to achieve the "Hi" serum phosphate target (≥6.5 mg/dL) or the "Lo" serum phosphate target (<5.5 mg/dL).

OUTCOMES

Primary outcome: Hierarchical composite outcome of all-cause mortality and all-cause hospitalization. Main secondary outcomes: Individual components of the primary outcome.

RESULTS

The trial is currently enrolling.

LIMITATIONS

HiLo will not adjudicate causes of hospitalizations or mortality and does not protocolize use of specific phosphate binder classes.

CONCLUSIONS

HiLo aims to address an important clinical question while more generally advancing methods for pragmatic clinical trials in nephrology by introducing multiple innovative features including stakeholder engagement in the study design, liberal eligibility criteria, use of electronic informed consent, engagement of dietitians to implement the interventions in real-world practice, leveraging electronic health records to eliminate dedicated study visits, remote monitoring of serum phosphate separation between trial arms, and use of a novel hierarchical composite outcome.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT04095039.

Challenges in the design, interpretation, and reporting of randomized controlled clinical studies on the health effects of whole foods

Given the challenges with nutrition research, the Canadian Nutrition Society and Intertek Health Sciences Inc held an expert consultation in late 2019 to discuss the development and implementation of best practices for clinical trials on whole foods. Key challenges in the design, interpretation, and reporting of clinical efficacy studies on whole foods and opportunities for the future development of best practices are reported. Novelty: Outlines existing tools, resources, and checklists for clinical nutrition trials and provides clear and tangible steps to develop best practices for studies on whole foods.

Evidence and practice: a review of vignettes in qualitative research

BACKGROUND

Developing and working through a PhD research study requires tenacity, continuous development and application of knowledge. It is paramount when researching sensitive topics to consider carefully the construction of tools for collecting data, to ensure the study is ethically robust and explicitly addresses the research question.

AIM

To explore how novice researchers can develop insight into aspects of the research process by developing vignettes as a research tool.

DISCUSSION

This article focuses on the use of vignettes to collect data as part of a qualitative PhD study investigating making decisions in the best interests of and on behalf of people with advanced dementia. Developing vignettes is a purposeful, conscious process. It is equally important to ensure that vignettes are derived from literature, have an evidence base, are carefully constructed and peer-reviewed, and are suitable to achieve the research's aims.

CONCLUSION

Using and analysing a vignette enables novice researchers to make sense of aspects of the qualitative research process and engage with it to appreciate terminology.

IMPLICATIONS FOR PRACTICE

Vignettes can provide an effective platform for discussion when researching topics where participants may be reluctant to share sensitive real-life experiences.

Remote clinical trials: A timely opportunity for a virtual reality approach and its potential application in neurology

The COVID-19 pandemic boosted the expansion and development of new remote models of care and clinical research modalities. Health systems are going to implement telemedical innovations in the near future. Virtual clinical trials (VCT), also known as remote or decentralized ones, may profoundly change the way how clinical studies are conducted, for the benefit of patients with chronic and neurological diseases who are often fragile and may have limited access to traditional healthcare facilities. Despite significant progress, several limitations still need to be addressed to implement telemedicine technologies for VCT. The information and communication technology (ICT) devices (e.g., mobile apps and wearables) may be applied to VCTs but show some practical issues that may hamper the compliance with rigorous research criteria and protocols. We herewith discuss the advantages and disadvantages of virtual reality (VR) in combination with other ICT devices and solutions to improve the conduction of VCT in patients with neurological disorders. The so-called "digital divide," that is, the gap between people who can and those who cannot access high-speed and broadband internet connections, and issues related to VR, such as VR sickness, should be addressed to improve larger VCT participation to neurological patients.

A Systematic Review and Meta-Analysis of Validation Studies Performed on Dietary Record Apps

Mobile dietary record apps have been increasingly validated by studies with various study designs. This review aims to evaluate the overall accuracy of dietary record apps in measuring the intake of energy, macro- and micronutrients, and food groups in real-life settings and the designs of validation studies. We systematically searched mobile dietary record validation studies published during the period from 2013 to 2019. We identified 14 studies for the systematic review, of which 11 studies were suitable for meta-analyses on energy intake and 8 studies on macronutrient intake. Mean differences and SDs of nutrient estimations between the app and the reference method from studies were pooled using a random-effects model. All apps underestimated energy intake when compared with their reference methods, with a pooled effect of -202 kcal/d (95% CI: -319, -85 kcal/d); the heterogeneity of studies was 72%. After stratification, studies that used the same food-composition table for both the app and the reference method had a lower level of heterogeneity (0%) and a pooled effect of -57 kcal/d (95% CI: -116, 2 kcal/d). The heterogeneity of studies in the differences in carbohydrate, fat, and protein intake was 54%, 73%, and 80%, with the pooled effect of -18.8 g/d, -12.7 g/d, and -12.2 g/d, respectively, after excluding outliers. The intakes of micronutrients and food groups were statistically nonsignificantly underestimated by the apps in most cases. In conclusion, dietary record apps underestimated food consumption compared with traditional dietary assessment methods. Moreover, varying study designs have been found across studies. Recommended practices for conducting validation studies were formulated including considering biomarkers as the reference, testing in a larger and more representative study population for a longer period, avoiding the learning effect of each method, and comparing food group or food item consumption in addition to comparing energy and nutrient intakes.

Using audiovisual vignettes to collect data remotely on complex clinical care: a practical insight

BACKGROUND

Vignettes are regularly used in nursing research and education to explore complex clinical situations. However, paper-based vignettes lack clinical realism and do not fully recreate the pressures, sights and sounds of clinical settings, limiting their usefulness when studying complex decision-making processes.

AIM

To discuss the approach taken by the authors in developing and implementing audiovisual vignettes to collect data remotely in a qualitative study.

DISCUSSION

The authors describe how they created audiovisual vignettes for a qualitative 'Think Aloud' study exploring how critical care nurses decide whether to restrain agitated patients with varying degrees of psychomotor agitation. They discuss the practicalities of filming, editing and hosting, as well as the theoretical and clinical background that informed the creation of the vignettes.

CONCLUSION

Audiovisual vignettes are a cost- and time-effective way of remotely exploring decision-making in challenging environments. This innovative method assists in studying decision-making under simulated clinical pressures and captures data about how people make complex decisions.

IMPLICATIONS FOR PRACTICE

Audiovisual vignettes are an innovative tool for collecting data and could also be used in educational settings and offer the opportunity to explore complex clinical decision making remotely. Clinical accuracy is essential for immersing participants and simulating an environment and its pressures. The method could be further enhanced by making vignettes responsive to participants' decisions.

Short-term health outcomes following whole blood donation: A nationwide, retrospective cohort study

BACKGROUND

Blood donation is associated with a number of adverse events. Most of these are both uncommon and nonsevere, leading to mild discomfort for the donor at worst. However, adverse events occurring outside of the donation facility have largely not been studied. In this study, we aim to further the understanding by performing the first large-scale analysis of short-term risks following whole blood donation.

METHODS

We set up a nationwide cohort of donors who donated whole blood between 1987 and 2018. Analyses were conducted using conditional logistic regression in a self-comparison design, where each donor was compared only to themselves, considering the 30-day risk of 16 outcomes following whole blood donation. Outcomes included cardiac/vascular diseases such as myocardial infarction, unspecified conditions such as fainting, accidents or external causes of injury, and death.

RESULTS

A total of 963,311 donors were included; of whom, 19,670 experienced at least one of the outcomes within 30 days of a blood donation. For fainting and hypotonia, we observed transient 2- to 5-fold risk increases on the day of donation and the subsequent 2-3 days. Importantly, the risk increase for the most pronounced effect corresponded to less than one additional events of fainting per 200,000 blood donations. Risks of all other outcomes were either unaffected or lower than expected right after blood donation.

DISCUSSION

To conclude, we found no evidence of new or unexpected short-term health effects after blood donation and confirmed that risks of hypotension-related events requiring hospital care are present but small.

Leveraging Digital Technology in Conducting Longitudinal Research on Mental Health in Pregnancy: Longitudinal Panel Survey Study

BACKGROUND

Collecting longitudinal data during and shortly after pregnancy is difficult, as pregnant women often avoid studies with repeated surveys. In contrast, pregnant women interact with certain websites at multiple stages throughout pregnancy and the postpartum period. This digital connection presents the opportunity to use a website as a way to recruit and enroll pregnant women into a panel study and collect valuable longitudinal data for research. These data can then be used to learn new scientific insights and improve health care.

OBJECTIVE

The objective of this paper is to describe the approaches applied and lessons learned from designing and conducting an online panel for health care research, specifically perinatal mood disorders. Our panel design and approach aimed to recruit a large sample (N=1200) of pregnant women representative of the US population and to minimize attrition over time.

METHODS

We designed an online panel to enroll participants from the pregnancy and parenting website BabyCenter. We enrolled women into the panel from weeks 4 to 10 of pregnancy (Panel 1) or from weeks 28 to 33 of pregnancy (Panel 2) and administered repeated psychometric assessments from enrollment through 3 months postpartum. We employed a combination of adaptive digital strategies to recruit, communicate with, and build trust with participants to minimize attrition over time. We were transparent at baseline about expectations, used monetary and information-based incentives, and sent personalized reminders to reduce attrition. The approach was participant-centric and leveraged many aspects of flexibility that digital methods afford.

RESULTS

We recruited 1179 pregnant women-our target was 1200-during a 26-day period between August 25 and September 19, 2016. Our strategy to recruit participants using adaptive sampling tactics resulted in a large panel that was similar to the US population of pregnant women. Attrition was on par with existing longitudinal observational studies in pregnant populations, and 79.2% (934/1179) of our panel completed another survey after enrollment. There were 736 out of 1179 (62.4%) women who completed at least one assessment in both the prenatal and postnatal periods, and 709 out of 1179 (60.1%) women who completed the final assessment. To validate the data, we compared participation rates and factors of perinatal mood disorders ascertained from this study with prior research, suggesting reliability of our approach.

CONCLUSIONS

A suitably designed online panel created in partnership with a digital media source that reaches the target audience is a means to leverage a conveniently sized and viable sample for scientific research. Our key lessons learned are as follows: sampling tactics may need to be adjusted to enroll a representative sample, attrition can be reduced by adapting to participants' needs, and study engagement can be boosted by personalizing interactions with the flexibility afforded by digital technologies.

Time as an outcome measure in fertility-related clinical studies: long-awaited

Time taken to achieve a live birth is an important consideration that is central to managing patient expectations during infertility treatment. However, time-related endpoints are not reported as standard in the majority of fertility-related clinical studies and there is no internationally recognized consensus definition for such endpoints. There is, therefore, a need for meaningful discussions around the selection of appropriate time-related treatment outcome measures for studies evaluating fertility treatments that will be relevant to diverse stakeholders (e.g. patients, healthcare professionals, clinical scientists, authorities and industry). Here, we provide a proposal for the evaluation of time-related outcome measures in fertility-related clinical studies, alongside associated definitions.

Do Digital Handover Checklists Influence the Clinical Outcome Parameters of Intensive Care Unit Patients? A Randomized Controlled Pilot Study

Background: Clinical handovers have been identified as high-risk situations for medical treatment errors. It has been shown that handover checklists lead to a reduced rate of medical errors and mortality. However, the influence of handover checklists on essential patient outcomes such as prevalence of sepsis, mortality, and length of hospitalization has not yet been investigated in a randomized controlled trial (RCT).

Objectives: The aim of the present pilot study was to estimate the effect of two different handover checklists on the 48 h sepsis-related organ failure assessment (SOFA) score and the feasibility of a respective clinical RCT.

Methods: Outcome parameters and feasibility were investigated implementing and comparing an intervention with a control checklist.

Design: Single center two-armed cluster randomized prospective crossover pilot study.

Setting: The study took place over three 1-month periods in an intensive care unit (ICU) setting at the University Hospital Aachen.

Patients/Participants: Data from 1,882 patients on seven ICU wards were assessed, of which 1,038 were included in the analysis.

Intervention: A digital standardized handover checklist (ISBAR₃) was compared to a control checklist (VICUR).

Main Outcome Measures: Primary outcome was the 2nd 24 h time window sepsis-related organ failure assessment (SOFA) score. Secondary outcomes were SOFA scores on the 3rd and 5th 24 h time window, mortality, reuptake, and length of stay; handover duration, degree of satisfaction, and compliance as feasibility-related outcomes.

Results: Different sepsis scores were observed only for the 1st 24 h time window after admission to the ICU, with higher values for ISBAR₃. With respect to the patient-centered outcomes, both checklists achieved similar results. Average handover duration was shorter for VICUR, whereas satisfaction and compliance were higher for ISBAR₃. However, overall compliance was low (25.4% for ISBAR₃ and 15.8% for VICUR).

Conclusions: Based on the results, a stratified randomization procedure is recommended for following RCTs, in which medical treatment errors should also be investigated as an additional variable. The use of control checklists is discouraged due to lower acceptance and compliance among healthcare practitioners. Measures should be undertaken to increase compliance with the use of checklists. Clinical outcome parameters should be carefully selected.

Trial Registration:ClinicalTrials.gov, Identifier [NCT03117088]. Registered April 14, 2017.

Multi-omics data integration considerations and study design for biological systems and disease

With the advancement of next-generation sequencing and mass spectrometry, there is a growing need for the ability to merge biological features in order to study a system as a whole. Features such as the transcriptome, methylome, proteome, histone post-translational modifications and the microbiome all influence the host response to various diseases and cancers. Each of these platforms have technological limitations due to sample preparation steps, amount of material needed for sequencing, and sequencing depth requirements. These features provide a snapshot of one level of regulation in a system. The obvious next step is to integrate this information and learn how genes, proteins, and/or epigenetic factors influence the phenotype of a disease in context of the system. In recent years, there has been a push for the development of data integration methods. Each method specifically integrates a subset of omics data using approaches such as conceptual integration, statistical integration, model-based integration, networks, and pathway data integration. In this review, we discuss considerations of the study design for each data feature, the limitations in gene and protein abundance and their rate of expression, the current data integration methods, and microbiome influences on gene and protein expression. The considerations discussed in this review should be regarded when developing new algorithms for integrating multi-omics data.

The American Society of Pain and Neuroscience (ASPN) Practical Guidelines to Study Design and Scientific Manuscript Preparation in Neuromodulation

Background

Healthcare clinical and even policy decisions are progressively made based on research-based evidence. The process by which the appropriate trials are developed and well-written manuscripts by means of evidence-based medicine recommendations has resulted in unprecedented necessity in evidence-based medicine in neuromodulation.

Methods

The essential considerations in the planning of neuromodulation research are discussed in the light of available scientific literature as well as the authors’ scientific expertise regarding research study design and scientific manuscript preparation.

Conclusion

This article should enable the reader to understand how to appropriately design a clinical research study and prepare scientific manuscripts. The high-quality and well-designed studies, when performed and reported effectively, support evidence-based medicine and foster improved patient outcomes.

Practice-informed guidance for undertaking remotely delivered mental health research

BACKGROUND

The assessment and monitoring of health conditions using remote or online delivery is an emerging interest in healthcare systems globally but is not routinely used in mental health research. There is a growing need to offer remotely delivered appointments in mental health research. There is a lack of practical guidance about how nurse researchers can undertake remote research appointments ethically and safely, while maintaining the scientific integrity of the research.

AIM

To provide mental health nurse researchers with information about important issues to consider when assessing the appropriateness of remotely delivered research and methods to support the development of a supportive research relationship.

DISCUSSION

The practice guidance and checklist include issues a nurse researcher should consider when assessing suitability and eligibility for remotely delivered research visits, such as ethical considerations and arrangements, safety, communication, and identifying participants requiring further support. This article addresses processes to follow for assessing mental capacity, obtaining informed consent and collaboratively completing research measures.

CONCLUSION

Remotely delivered research appointments could be acceptable and efficient ways to obtain informed consent and collect data. Additional checks need to be in place to identify and escalate concerns about safeguarding or risks.

IMPLICATIONS FOR PRACTICE

Practical guidance for mental health nurse researchers when determining the appropriateness of remote research visits for participants, and an adaptable checklist for undertaking remote research appointments are outlined.

Determining sample size and length of follow-up for smartphone-based digital phenotyping studies

OBJECTIVE

Studies that use patient smartphones to collect ecological momentary assessment and sensor data, an approach frequently referred to as digital phenotyping, have increased in popularity in recent years. There is a lack of formal guidelines for the design of new digital phenotyping studies so that they are powered to detect both population-level longitudinal associations as well as individual-level change points in multivariate time series. In particular, determining the appropriate balance of sample size relative to the targeted duration of follow-up is a challenge.

MATERIALS AND METHODS

We used data from 2 prior smartphone-based digital phenotyping studies to provide reasonable ranges of effect size and parameters. We considered likelihood ratio tests for generalized linear mixed models as well as for change point detection of individual-level multivariate time series.

RESULTS

We propose a joint procedure for sequentially calculating first an appropriate length of follow-up and then a necessary minimum sample size required to provide adequate power. In addition, we developed an accompanying accessible sample size and power calculator.

DISCUSSION

The 2-parameter problem of identifying both an appropriate sample size and duration of follow-up for a longitudinal study requires the simultaneous consideration of 2 analysis methods during study design.

CONCLUSION

The temporally dense longitudinal data collected by digital phenotyping studies may warrant a variety of applicable analysis choices. Our use of generalized linear mixed models as well as change point detection to guide sample size and study duration calculations provide a tool to effectively power new digital phenotyping studies.

Sample size, sample size planning, and the impact of study context: systematic review and recommendations by the example of psychological depression treatment

BACKGROUND

Sample size planning (SSP) is vital for efficient studies that yield reliable outcomes. Hence, guidelines, emphasize the importance of SSP. The present study investigates the practice of SSP in current trials for depression.

METHODS

Seventy-eight randomized controlled trials published between 2013 and 2017 were examined. Impact of study design (e.g. number of randomized conditions) and study context (e.g. funding) on sample size was analyzed using multiple regression.

RESULTS

Overall, sample size during pre-registration, during SSP, and in published articles was highly correlated (r's ≥ 0.887). Simultaneously, only 7-18% of explained variance related to study design (p = 0.055-0.155). This proportion increased to 30-42% by adding study context (p = 0.002-0.005). The median sample size was N = 106, with higher numbers for internet interventions (N = 181; p = 0.021) compared to face-to-face therapy. In total, 59% of studies included SSP, with 28% providing basic determinants and 8-10% providing information for comprehensible SSP. Expected effect sizes exhibited a sharp peak at d = 0.5. Depending on the definition, 10.2-20.4% implemented intense assessment to improve statistical power.

CONCLUSIONS

Findings suggest that investigators achieve their determined sample size and pre-registration rates are increasing. During study planning, however, study context appears more important than study design. Study context, therefore, needs to be emphasized in the present discussion, as it can help understand the relatively stable trial numbers of the past decades. Acknowledging this situation, indications exist that digital psychiatry (e.g. Internet interventions or intense assessment) can help to mitigate the challenge of underpowered studies. The article includes a short guide for efficient study planning.

Two Questions About the Design of Cluster Randomized Trials: A Tutorial

This is a short tutorial on two key questions that pertain to cluster randomized trials (CRTs): 1) Should I perform a CRT? and 2) If so, how do I derive the sample size? In summary, a CRT is the best option when you "must" (e.g., the intervention can only be administered to a group) or you "should" (e.g., because of issues such as feasibility and contamination). CRTs are less statistically efficient and usually more logistically complex than individually randomized trials, and so reviewing the rationale for their use is critical. The most straightforward approach to the sample size calculation is to first perform the calculation as if the design were randomized at the level of the patient and then to inflate this sample size by multiplying by the "design effect", which quantifies the degree to which responses within a cluster are similar to one another. Although trials with large numbers of small clusters are more statistically efficient than those with a few large clusters, trials with large clusters can be more feasible. Also, if results are to be compared across individual sites, then sufficient sample size will be required to attain adequate precision within each site. Sample size calculations should include sensitivity analyses, as inputs from the literature can lack precision. Collaborating with a statistician is essential. To illustrate these points, we describe an ongoing CRT testing a mobile-based app to systematically engage families of intensive care unit patients and help intensive care unit clinicians deliver needs-targeted palliative care.

Pharmacometrics-Based Considerations for the Design of a Pharmacogenomic Clinical Trial Assessing Irinotecan Safety

PURPOSE

Pharmacometric models provide useful tools to aid the rational design of clinical trials. This study evaluates study design-, drug-, and patient-related features as well as analysis methods for their influence on the power to demonstrate a benefit of pharmacogenomics (PGx)-based dosing regarding myelotoxicity.

METHODS

Two pharmacokinetic and one myelosuppression model were assembled to predict concentrations of irinotecan and its metabolite SN-38 given different UGT1A1 genotypes (poor metabolizers: CLSN-38: -36%) and neutropenia following conventional versus PGx-based dosing (350 versus 245 mg/m2 (-30%)). Study power was assessed given diverse scenarios (n = 50-400 patients/arm, parallel/crossover, varying magnitude of CLSN-38, exposure-response relationship, inter-individual variability) and using model-based data analysis versus conventional statistical testing.

RESULTS

The magnitude of CLSN-38 reduction in poor metabolizers and the myelosuppressive potency of SN-38 markedly influenced the power to show a difference in grade 4 neutropenia (<0.5·109 cells/L) after PGx-based versus standard dosing. To achieve >80% power with traditional statistical analysis (χ2/McNemar's test, α = 0.05), 220/100 patients per treatment arm/sequence (parallel/crossover study) were required. The model-based analysis resulted in considerably smaller total sample sizes (n = 100/15 given parallel/crossover design) to obtain the same statistical power.

CONCLUSIONS

The presented findings may help to avoid unfeasible trials and to rationalize the design of pharmacogenetic studies.

Low-coverage sequencing cost-effectively detects known and novel variation in underrepresented populations

Genetic studies in underrepresented populations identify disproportionate numbers of novel associations. However, most genetic studies use genotyping arrays and sequenced reference panels that best capture variation most common in European ancestry populations. To compare data generation strategies best suited for underrepresented populations, we sequenced the whole genomes of 91 individuals to high coverage as part of the Neuropsychiatric Genetics of African Population-Psychosis (NeuroGAP-Psychosis) study with participants from Ethiopia, Kenya, South Africa, and Uganda. We used a downsampling approach to evaluate the quality of two cost-effective data generation strategies, GWAS arrays versus low-coverage sequencing, by calculating the concordance of imputed variants from these technologies with those from deep whole-genome sequencing data. We show that low-coverage sequencing at a depth of ≥4× captures variants of all frequencies more accurately than all commonly used GWAS arrays investigated and at a comparable cost. Lower depths of sequencing (0.5-1×) performed comparably to commonly used low-density GWAS arrays. Low-coverage sequencing is also sensitive to novel variation; 4× sequencing detects 45% of singletons and 95% of common variants identified in high-coverage African whole genomes. Low-coverage sequencing approaches surmount the problems induced by the ascertainment of common genotyping arrays, effectively identify novel variation particularly in underrepresented populations, and present opportunities to enhance variant discovery at a cost similar to traditional approaches.

Effectiveness of the oral human attenuated pentavalent rotavirus vaccine (RotaTeq™) postlicensure: a meta-analysis-2006-2020

BACKGROUND

Rotavirus (RV), which causes RV-associated gastroenteritis (RVGE), has accounted for considerable morbidity. We aimed to assess the effectiveness (VE) of the oral pentavalent RV vaccine (RotaTeq™) in real-world settings in children and infants with gastroenteritis.

METHODS

We performed a systematic search for peer-reviewed studies published between 1 January 2006 and 1 May 2020 and a meta-analysis to calculate the VE of RotaTeq™ vaccine. The primary outcome was the pooled three-dose vaccine VE. Stratified analysis of the vaccine VEs was performed according to dosages, study design, population age, socioeconomic status (SES), introduction condition, control group types, outcomes of RV disease, and RV strains.

RESULTS

After screening 2359 unique records, 28 studies were included and meta-analyzed. The overall VE estimate was 84% (95% confidence interval [CI], 80-87%). Stratified analyses revealed a nonnegligible impact of factors such as study design and SES. Other factors did not show great impart to VE with no significant differences between groups.

CONCLUSIONS

RotaTeq™ is effective against RV infection, especially in high-income countries. Adopting suitable study methods and expansion of RV surveillance in low-income regions is crucial to assess VE in real-life settings and provide feasible vaccine regimens to improve vaccine VE.

The science of spin: targeted strategies to manufacture doubt with detrimental effects on environmental and public health

BACKGROUND

Numerous groups, such as the tobacco industry, have deliberately altered and misrepresented knowable facts and empirical evidence to promote an agenda, often for monetary benefit, with consequences for environmental and public health. Previous research has explored cases individually, but none have conducted an in-depth comparison between cases. The purpose of this study was to compile a comprehensive list of tactics used by disparate groups and provide a framework for identifying further instances of manufactured doubt.

METHODS

We examined scholarly books, peer-reviewed articles, well-researched journalism pieces, and legal evidence related to five disparate industries and organizations selected for their destructive impacts on environmental and public health (tobacco, coal, and sugar industries, manufacturers of the pesticide Atrazine, and the Marshall Institute, an institute focused on climate change research, and other scientists from the era that associated with those in the Institute). These documents provided evidence for a list of tactics used to generate pro-industry spin and manufacture doubt about conferred harm. We then identified trends among sets of strategies that could explain their differential use or efficacy.

RESULTS

We recognized 28 unique tactics used to manufacture doubt. Five of these tactics were used by all five organizations, suggesting that they are key features of manufactured doubt. The intended audience influences the strategy used to misinform, and logical fallacies contribute to their efficacy.

CONCLUSIONS

This list of tactics can be used by others to build a case that an industry or group is deliberately manipulating information associated with their actions or products. Improved scientific and rhetorical literacy could be used to render them less effective, depending on the audience targeted, and ultimately allow for the protection of both environmental health and public health more generally.

Misclassification and measurement error - planning a study and interpreting results

BACKGROUND

Measurement error must always be considered when planning a research project and interpreting its results. The accuracy of some data collected during a study can often be confidently assured, but more than one measurement or observer is needed to assess exposure and outcomes status in cases where clinical measurement is prone to measurement error. Little attention is paid in nursing research to misclassification and measurement error. Bias is often discussed in nursing research education, but not its potential consequences or measures that can be taken to improve the study's quality.

AIM

To present examples of random measurement error - misclassification of a binary outcome - in a continuous exposure and outcomes variable, to address this gap in nurses' research training.

DISCUSSION

The article discusses the relationship between exposure and outcome in the absence and presence of measurement error using risk (relative risk) and association using correlation. It provides methods to estimate the true value of these measures of risk and association, when only given the clinical measurements with errors.

CONCLUSION

If the assumption of random error holds, attenuation of risk or association towards the null will occur.

IMPLICATIONS FOR PRACTICE

Understanding the effect of measurement error including misclassification will enable researchers to interpret the results of their studies, and to take into consideration this potential error when planning and conducting a study.

Use of modified Delphi introduces the risk of chronological bias during clinical research interventions

BACKGROUND

A study aimed at reducing the time spent on the phone obtaining insurance preauthorisation in a neurosurgical clinic was successfully completed. However, the researchers were unable to reject the null hypothesis because of a combination of chronological bias and the Hawthorne effect.

AIM

To increase nurse researchers' awareness of the potential to introduce a chronological bias as a confounder in clinical research and suggest potential alternative approaches to study design.

DISCUSSION

The researcher shared the study's purpose, design and outcome measure with the participants before collecting the baseline data. This enabled the participants to alter their practice before the intervention was implemented (a chronological bias) and change their behaviour surrounding the outcome (the Hawthorne effect).

CONCLUSION

The use of the Delphi method became a catalyst for change before the collection of baseline data, the combination of chronological bias and the Hawthorne effect affecting the study's results.

IMPLICATIONS FOR PRACTICE

Nurse researchers seeking to improve practice should collect baseline data before informing participants and consider the risks and benefits of blinding (concealment) surrounding the outcome.

When and how to use factorial design in nursing research

BACKGROUND

Quantitative research designs are broadly classified as being either experimental or quasi-experimental. Factorial designs are a form of experimental design and enable researchers to examine the main effects of two or more independent variables simultaneously. They also enable researchers to detect interactions among variables.

AIM

To present the features of factorial designs.

DISCUSSION

This article provides an overview of the factorial design in terms of its applications, design features and statistical analysis, as well as its advantages and disadvantages.

CONCLUSION

Factorial designs are highly efficient for simultaneously evaluating multiple interventions and present the opportunity to detect interactions amongst interventions. Such advantages have led researchers to advocate for the greater use of factorial designs in research when participants are scarce and difficult to recruit.

IMPLICATIONS FOR PRACTICE

A factorial design is a cost-effective way to determine the effects of combinations of interventions in clinical research, but it poses challenges that need to be addressed in determining appropriate sample size and statistical analysis.

A systematic review

AIM

The aim of this review is to assess study design and risk of bias related to primary outcome in recently published randomized controlled trials (RCTs) in periodontology.

METHOD

An electronic (Medline, EMBASE and Cochrane library) and a manual search were completed to detect RCTs in humans, with an outcome in the field of periodontology and published in English from January 2018 up to March 2020.

RESULTS

Data extraction of 318 publications meeting the inclusion criteria was performed by two reviewers. Most studies adopted a parallel-group superiority design in a university setting. Overall, 54% of papers reported the primary outcome and relative sample size calculation, while only 37% also included reproducibility estimates relative to the primary outcome. Papers published in journals with higher impact factors had better compliance with primary outcome reporting and lower overall risk of bias scores.

CONCLUSION

Improvements in the quality of RCTs in periodontology are still needed. The importance of defining a clinically relevant study primary outcome and building the study around it needs to be emphasized. Furthermore, RCTs in periodontology could consider, when appropriate, some of the study design options which facilitate application of the principles of personalized medicine.

The impact of health-related quality of life and depressive symptoms on blood donor career-Results from the Danish blood donor study

BACKGROUND

Blood donors report better health-related quality of life (HRQL) than non-donors. Likewise, donors reporting good health are less likely to stop donating and have a higher donation frequency. This is evidence of the healthy donor effect (HDE). This study is the first to investigate the impact of HRQL and depressive symptoms on subsequent donor career.

STUDY DESIGN AND METHODS

Prospective cohort study includes 102,065 participants from the Danish Blood Donor Study applying the 12-item short-form health survey (SF-12) measuring a mental (MCS) and a physical component score (PCS) and the Major Depression Inventory (MDI). Poisson and Cox regression models were used to assess the effect of SF-12 and MDI scores on donation frequency and donor cessation. Higher MCS/PCS scores indicate good HRQL, while higher MDI score indicates higher experience of depressive symptoms.

RESULTS

For both sexes, MCS was positively correlated with donation frequency for up to 5 years, and similarly for PCS among women. A negative correlation between MDI score and donation frequency in the year following assessment was observed only among men. No correlation was observed among women. An increase in both MCS and PCS was associated with a lower risk of donation cessation in both sexes, while an increase in MDI score was only associated with an increased risk of donation cessation in men.

CONCLUSION

MCS, PCS, and MDI score affect donor career. Thus, adjusting for donation frequency may reduce HDE-bias in donor health research. However, because of the small effect sizes, other ways of quantifying HDE may be beneficial.

The Danish National Youth Study 2019: study design and participant characteristics

AIM

To present the study design, study population and questionnaire content of the Danish National Youth Study 2019, and to describe the differences between participants and non-participants regarding demographic and socioeconomic characteristics.

METHOD

The Danish National Youth Study 2019 is a nationwide web-survey among high school students in Denmark. Data was collected from January to April 2019 through a self-administered questionnaire in the classroom. The questionnaire included 120 questions on, for example, physical and mental health, health behaviour and well-being. Data collection took place at 50 general high schools, 32 preparatory high schools, 15 commercial high school and 19 technical high schools.

RESULTS

A total of 29,086 students participated (20,287 general high school students, 2,113 preparatory higher school students, 4027 commercial high school students and 2659 technical high school students) corresponding to 66% of the students in the 88 participating schools (31% of invited schools). Among students, 55% were female and the mean age was 17.8 years. Participants were more likely to be female, to be younger, to be of Danish origin, and have family disposable income in the highest quartile compared to non-participants.

CONCLUSIONS

The Danish National Youth Study 2019 contributes to knowledge on high school students' health, health behaviour and well-being that can support health planning and prioritizing, through identification of specific risk groups at both local and national level. The study also offers great opportunities for future research as it provides possibility of linkage to various Danish national registers.

Evaluation of Therapeutic Strategies to Reduce the Number of Thrombotic Events in Patients With Polycythemia Vera and Essential Thrombocythemia

Thrombosis is the largest contributor to morbidity and mortality in patients with polycythemia vera (PV) and essential thrombocythemia (ET). Our understanding of the risk factors and pathophysiology of thrombosis in PV and ET patients is developing, including recent insights into the role of aberrant platelet-neutrophil interactions, JAK2 mutated endothelial cells and the pro-thrombotic inflammatory milieu. To date, few available therapies have demonstrated the ability to reduce the thrombotic burden in patients with these diseases. Although numerous therapeutic agents have been investigated in both PV and ET patients, few studies are designed to assess their impact on thrombotic events. In this review, we first describe the burden of thrombosis in patients with these myeloproliferative neoplasms (MPNs) and briefly explore their pathophysiologic mechanisms. We then critically assess and summarize the evidence behind currently available therapies with attention toward thrombotic endpoints. Finally, we describe a path forward for clinical research in MPNs that involves surrogate endpoint validation, biomarker development, and clinical trial design strategies in order to accurately assess reduction of thrombotic events when evaluating novel therapies.

Review of the Technical, Toxicological, and PKPD Considerations for Conducting Inhalation Toxicity Studies on Biologic Pharmaceuticals-The Outcome of a Cross-Industry Working Group Survey

The inhaled route is still a relatively novel route for delivering biologics and poses additional challenges to those encountered with inhaled small molecules, further complicating the design and interpretation of toxicology studies. A working group formed to summarize the current knowledge of inhaled biologics across industry and to analyze data collated from an anonymized cross-industry survey comprising 12 inhaled biologic case studies (18 individual inhalation toxicity studies on monoclonal antibodies, fragment antibodies, domain antibodies, oligonucleotides, and proteins/peptides). The output of this working group provides valuable insights into the issues faced when conducting toxicology studies with inhaled biologics, including common technical considerations on aerosol generation, use of young and sexually mature nonhuman primates, pharmacokinetic/pharmacodynamic modeling, exposure and immunogenicity assessment, maximum dose setting, and no observed adverse effect levels determination. Although the current data set is too small to allow firm conclusions, testing of novel biologics remains an active area and is likely to remain so for molecules where delivery via the inhaled route is beneficial. In the future, it is hoped others will continue to share their experiences and build on the conclusions of this review to further improve our understanding of these complex issues and, ultimately, facilitate the safe introduction of inhaled biologics into clinical use.

Heterogeneity of Recent Phase 3 Complicated Urinary Tract Infection Clinical Trials

Background

For new antibiotics developed to treat antibiotic-resistant Gram-negative infections, the US Food and Drug Administration (FDA) regulatory pathway includes complicated urinary tract infection (cUTI) clinical trials in which the clinical isolates are susceptible to the active control. This allows for inferential testing in a noninferiority study design. Although complying with regulatory guidelines, individual clinical trials may differ substantially in design and patient population. To determine variables that impacted patient selection and outcome parameters, 6 recent cUTI trials that were pivotal to an new drug application (NDA) submission were reviewed.

Methods

This selective descriptive analysis utilized cUTI trial data, obtained from publicly disclosed information including FDA documents and peer-reviewed publications, from 6 new antibiotics developed to treat multidrug-resistant Gram-negative infections: ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, cefiderocol, plazomicin, and fosfomycin. Eravacycline was not approved for cUTI and is not included.

Results

Microbiologic modified intent-to-treat sample size, age, proportions of female patients, acute pyelonephritis (AP), Escherichia coli and other pathogens at baseline, protocol-specified switch to oral antibiotic, and the noninferiority margin were compared. Outcome data included clinical response, microbiologic eradication, and composite outcomes, including a subset of patients with AP.

Conclusions

A study design can follow regulatory guidelines but still have variable populations. The proportion of AP within a study varied greatly and influenced population demographics (age, gender) and baseline microbiology. A smaller proportion of AP resulted in an older patient population, fewer females, less E coli, and lower proportions of patients achieving success. Fluoroquinolones and piperacillin/tazobactam should be reconsidered as active comparators given the high rates of resistance to these antibiotics.

Drug development for cystic fibrosis

The first regulatory approval for a drug developed specifically for cystic fibrosis (CF) occurred in 1993, and since then, several other drugs have been approved. Median predicted survival in people with CF in the United States has increased from approximately 30 years to 44.4 years over that same period. Highly effective modulators of the cystic fibrosis transmembrane conductance regulator became available to approximately 90% of people with CF ages 12 years and older in the United States in 2019 and in Europe in 2020. These transformative therapies will surely reduce morbidity and further extend longevity. The drug development pipeline is filled with therapies that address most aspects of CF disease. As survival and CF therapies advance, and the complexity of CF care increases, the process of drug development has become more sophisticated. In addition, detecting meaningful changes in outcome measures has become more difficult as the health status of people with CF improves. Innovative approaches are required to continue to advance drug development in CF. This review provides a general overview of drug development from the preclinical phase through Phase IV. Special considerations with respect to CF are integrated into the discussion of each phase of drug development. As CF care evolves, drug development must continue to evolve as well, until a one-time cure is available to all people with CF.

The challenge of biased evidence in conservation

Efforts to tackle the current biodiversity crisis need to be as efficient and effective as possible given chronic underfunding. To inform decision-makers of the most effective conservation actions, it is important to identify biases and gaps in the conservation literature to prioritize future evidence generation. We used the Conservation Evidence database to assess the state of the global literature that tests conservation actions for amphibians and birds. For the studies in the database, we investigated their spatial and taxonomic extent and distribution across biomes, effectiveness metrics, and study designs. Studies were heavily concentrated in Western Europe and North America for birds and particularly for amphibians, and temperate forest and grassland biomes were highly represented relative to their percentage of land coverage. Studies that used the most reliable study designs-before-after control-impact and randomized controlled trials-were the most geographically restricted and scarce in the evidence base. There were negative spatial relationships between the numbers of studies and the numbers of threatened and data-deficient species worldwide. Taxonomic biases and gaps were apparent for amphibians and birds-some entire orders were absent from the evidence base-whereas others were poorly represented relative to the proportion of threatened species they contained. Metrics used to evaluate effectiveness of conservation actions were often inconsistent between studies, potentially making them less directly comparable and evidence synthesis more difficult. Testing conservation actions on threatened species outside Western Europe, North America, and Australasia should be prioritized. Standardizing metrics and improving the rigor of study designs used to test conservation actions would also improve the quality of the evidence base for synthesis and decision-making.

Selfie consents, remote rapport, and Zoom debriefings: collecting qualitative data amid a pandemic in four resource-constrained settings

In-person interactions have traditionally been the gold standard for qualitative data collection. The COVID-19 pandemic required researchers to consider if remote data collection can meet research objectives, while retaining the same level of data quality and participant protections. We use four case studies from the Philippines, Zambia, India and Uganda to assess the challenges and opportunities of remote data collection during COVID-19. We present lessons learned that may inform practice in similar settings, as well as reflections for the field of qualitative inquiry in the post-COVID-19 era. Key challenges and strategies to overcome them included the need for adapted researcher training in the use of technologies and consent procedures, preparation for abbreviated interviews due to connectivity concerns, and the adoption of regular researcher debriefings. Participant outreach to allay suspicions ranged from communicating study information through multiple channels to highlighting associations with local institutions to boost credibility. Interviews were largely successful, and contained a meaningful level of depth, nuance and conviction that allowed teams to meet study objectives. Rapport still benefitted from conventional interviewer skills, including attentiveness and fluency with interview guides. While differently abled populations may encounter different barriers, the included case studies, which varied in geography and aims, all experienced more rapid recruitment and robust enrollment. Reduced in-person travel lowered interview costs and increased participation among groups who may not have otherwise attended. In our view, remote data collection is not a replacement for in-person endeavours, but a highly beneficial complement. It may increase accessibility and equity in participant contributions and lower costs, while maintaining rich data collection in multiple study target populations and settings.