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Blecha S, Brandstetter S, Dodoo-Schittko F, Brandl M, Graf BM, Bein T, Apfelbacher C. Acceptability of a German multicentre healthcare research study: a survey of research personnels' attitudes, experiences and work load. BMJ Open 2018; 8:e023166. [PMID: 30249633 PMCID: PMC6157522 DOI: 10.1136/bmjopen-2018-023166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The DACAPO study as a multicentre nationwide observational healthcare research study investigates the influence of quality of care on the quality of life in patients with acute respiratory distress syndrome. The aim of this study was to investigate the acceptability to the participating research personnels by assessing attitudes, experiences and workload associated with the conduct of the DACAPO study. DESIGN, SETTING AND PARTICIPANTS A prospective anonymous online survey was sent via email account to 169 participants in 65 study centres. The questionnaire included six different domains: (1) training for performing the study; (2) obtaining informed consent; (3) data collection; (4) data entry using the online documentation system; (5) opinion towards the study and (6) personal data. Descriptive data analysis was carried out. RESULTS A total of 78 participants took part (46%) in the survey, 75 questionnaires (44%) could be evaluated. 51% were senior medical specialists. 95% considered the time frame of the training as appropriate and the presentation was rated by 93% as good or very good. Time effort for obtaining consent, data collection and entry was considered by 41% as a burden. Support from the coordinating study centre was rated as good or very good by more than 90% of respondents. While the DACAPO study was seen as scientifically relevant by 81%, only 45% considered the study results valuable for improving patient care significantly. CONCLUSION Collecting feedback on the acceptability of a large multicentre healthcare research study provided important insights. Recruitment and data acquisition was mainly performed by physicians and often regarded as additional time burden in clinical practice. Reducing the amount of data collection and simplifying data entry could facilitate the conduct of healthcare research studies and could improve motivation of researchers in intensive care medicine. TRIAL REGISTRATION NUMBER NCT02637011; Pre-results.
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Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Bernhard M Graf
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany
| | - Thomas Bein
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
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Turnbull AE, Sahetya SK, Biddison ELD, Hartog CS, Rubenfeld GD, Benoit DD, Guidet B, Gerritsen RT, Tonelli MR, Curtis JR. Competing and conflicting interests in the care of critically ill patients. Intensive Care Med 2018; 44:1628-1637. [PMID: 30046872 DOI: 10.1007/s00134-018-5326-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
Abstract
Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. .,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - E Lee Daugherty Biddison
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - Christiane S Hartog
- Department for Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany.,Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Kreischa, Germany.,Patient- and Family-Centered Care, Klinik Bavaria, Kreischa, Germany
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.,Sorbonne Universités, Université Pierre et Marie Curie, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), UMR S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Rik T Gerritsen
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Mark R Tonelli
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
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Abstract
Enrolling severely burn injured patients into prospective research studies poses specific challenges to investigators. The authors describe their experience of recruiting adults with ≥20% TBSA burns or inhalation injury admitted to a single academic burn unit into observational research with minimally invasive specimen collection. The authors outline iterative changes that they made to their recruitment processes in response to perceived weaknesses leading to delays in enrollment. The primary outcome was the change in days to consent for enrolled patients or cessation of recruitment for nonenrolled patients before and after the interventional modifications. The authors assessed change in overall enrollment as a secondary outcome. Study enrollment was approximately 70% in both 4-month study periods before and after the intervention. Following the intervention, time to consent by surrogate decision maker decreased from a median of 26.5 days (interquartile range [IQR] 14-41) to 3 days (IQR 3-6) (P = .004). Time to initial consent by patient changed from a median of 15 days (IQR 2-30) to 3 days (IQR 2-6) (P = .27). Time to decline for nonenrolled patients decreased from a median of 12 days (IQR 6.5-27) to 1.5 days (IQR 1-3.5) (P = .026). Both the findings of the study and a brief literature review suggest that careful design of the recruitment protocol, increased experience of the study team, and broad time windows for both approach and enrollment improve the efficiency of recruiting critically injured burn patients into research.
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Rowlands C, Rooshenas L, Fairhurst K, Rees J, Gamble C, Blazeby JM. Detailed systematic analysis of recruitment strategies in randomised controlled trials in patients with an unscheduled admission to hospital. BMJ Open 2018; 8:e018581. [PMID: 29420230 PMCID: PMC5829602 DOI: 10.1136/bmjopen-2017-018581] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine the design and findings of recruitment studies in randomised controlled trials (RCTs) involving patients with an unscheduled hospital admission (UHA), to consider how to optimise recruitment in future RCTs of this nature. DESIGN Studies within the ORRCA database (Online Resource for Recruitment Research in Clinical TriAls; www.orrca.org.uk) that reported on recruitment to RCTs involving UHAs in patients >18 years were included. Extracted data included trial clinical details, and the rationale and main findings of the recruitment study. RESULTS Of 3114 articles populating ORRCA, 39 recruitment studies were eligible, focusing on 68 real and 13 hypothetical host RCTs. Four studies were prospectively planned investigations of recruitment interventions, one of which was a nested RCT. Most recruitment papers were reports of recruitment experiences from one or more 'real' RCTs (n=24) or studies using hypothetical RCTs (n=11). Rationales for conducting recruitment studies included limited time for informed consent (IC) and patients being too unwell to provide IC. Methods to optimise recruitment included providing patients with trial information in the prehospital setting, technology to allow recruiters to cover multiple sites, screening logs to uncover recruitment barriers, and verbal rather than written information and consent. CONCLUSION There is a paucity of high-quality research into recruitment in RCTs involving UHAs with only one nested randomised study evaluating a recruitment intervention. Among the remaining studies, methods to optimise recruitment focused on how to improve information provision in the prehospital setting and use of screening logs. Future research in this setting should focus on the prospective evaluation of the well-developed interventions to optimise recruitment.
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Affiliation(s)
- Ceri Rowlands
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Katherine Fairhurst
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Jonathan Rees
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Carrol Gamble
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jane M Blazeby
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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The Experience of Surrogate Decision Makers on Being Approached for Consent for Patient Participation in Research. A Multicenter Study. Ann Am Thorac Soc 2018; 14:238-245. [PMID: 27849142 DOI: 10.1513/annalsats.201606-425oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Recruitment in critical care research differs from other contexts in important ways: patients lack decision-making capacity, uncertainty exists regarding patient prognosis, and critical illnesses are often associated with appreciable morbidity and mortality. OBJECTIVES We aimed to describe the experiences of surrogate decision makers (SDMs) in being approached for consent for critically ill patients to participate in research. METHODS A multicenter, qualitative study involving semistructured interviews with 26 SDMs, who provided or declined surrogate consent for research participation, at 5 Canadian centers nested within a multicenter observational study of research recruitment practices. Transcripts were reviewed by three qualitative researchers, and data were analyzed using grounded theory and a narrative critical analysis. MEASUREMENTS AND MAIN RESULTS SDMs were guided by an overarching desire for the patient to live. Surrogate research decision-making involved three sequential stages: (1) being approached; (2) reflecting on participation; and (3) making a decision. In stage 1, SDMs identified factors (their expectations, how they were approached, the attributes of the person approaching, and study risks and benefits) that characterized their consent encounter and affirmed a preference to be approached in person. If SDMs perceived the risk of participation to be too high or felt patients may not benefit from participation, they did not contemplate further. In stage 2, SDMs who knew the patient's wishes or had a deeper understanding of research prioritized the patient's wishes and the perceived benefits of participation. Without this information, SDMs prioritized obtaining more and better care for the patient, considered what was in their mutual best interests, and valued healthcare professional's knowledge. Trust in healthcare professionals was essential to proceeding further. In stage 3, SDMs considered six factors in rendering decisions. CONCLUSIONS SDMs engaged in three sequential stages and considered six factors in making surrogate decisions for research participation. Surrogates' assessments of the risks and benefits of participation and their trust in healthcare professionals were critical factors in research decision-making. By conceptualizing surrogate decision-making for research in stages, future research can develop and test procedures to enhance the surrogate research decision-making process.
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Ecarnot F, Quenot JP, Besch G, Piton G. Ethical challenges involved in obtaining consent for research from patients hospitalized in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S41. [PMID: 29302597 DOI: 10.21037/atm.2017.04.42] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Clinical research remains a vital contributor to medical knowledge, and is an established and integral part of the practice of medicine worldwide. Respect for patient autonomy and ethical principles dictate that informed consent must be obtained from subjects before they can be enrolled into clinical research, yet these conditions may be difficult to apply in real practice in the intensive care unit (ICU). A number of factors serve to complexify the consent process in critically ill patients, notably decisional incapacity of the patient due to illness or sedation. Obtaining consent for research from a designated proxy or family member, commonly termed a "surrogate decision maker" (SDM) may be difficult, since SDMs dealing with the emotional, psychological and logistic impact of a sudden hospitalisation of their loved-one are not always receptive to the idea of research or emotionally equipped to reflect rationally on the opportunities being proposed to them. In addition, time constraints and workload pressures on the attending physician may render consent opportunities unfeasible, and the resulting loss of eligible patients could represent a bias in clinical trials, or limit the generalizability of their results. Alternative procedures such as deferred or waived consent have been used in the past and may be suitable alternatives in certain conditions, provided appropriate approval from institutional review boards (IRBs) can be obtained, in accordance with existing legislation. Some of the main questions inherent to the conduct of clinical research in critically ill patients are discussed in this review.
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Affiliation(s)
- Fiona Ecarnot
- Department of Cardiology, University Hospital, Besancon, France.,EA3920, University of Burgundy Franche-Comté, Besancon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, 14 rue Paul Gaffarel, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Guillaume Besch
- EA3920, University of Burgundy Franche-Comté, Besancon, France.,Department of Anesthesiology and Surgical Intensive Care Unit, University Hospital, Besancon, France
| | - Gaël Piton
- EA3920, University of Burgundy Franche-Comté, Besancon, France.,Department of Critical Care, University Hospital, Besancon, France
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Abstract
OBJECTIVES Seeking consent for minimal risk research in the ICU poses challenges, especially when the research is time-sensitive. Our aim was to determine the extent to which ICU patients or surrogates support a deferred consent process for a minimal risk study without the potential for direct benefit. DESIGN Prospective cohort study. SETTING Five ICUs within a tertiary care hospital. PATIENTS Newly admitted ICU patients 18 years old or older. INTERVENTIONS We administered an eight-item verbal survey to patients or surrogates approached for consent to participate in a minimal risk, ICU-based study. The parent study involved noninvasive collection of biosamples and clinical data at the time of ICU admission and again 3 days later. If patients had capacity at the time of ICU admission, or if a surrogate was readily available, consent was sought prior to initial sample collection; otherwise, a waiver of consent was granted, and deferred consent was sought 3 days later. Quantitative and qualitative data were analyzed. MEASUREMENTS AND MAIN RESULTS One hundred fifty-seven individuals were approached for consent to participate in the parent study; none objected to the consent process. One hundred thirty-five of 157 (86%) competed the survey, including 94 who consented to the parent study and 41 who declined. Forty-four of 60 individuals (73%) approached for deferred consent responded positively to the question "Did we make the right choice in waiting until now to ask your consent?" three of 60 (5%) responded negatively, and 13 of 60 (22%) made a neutral or unrelated response. The most common reason given for endorsing the deferred consent process was the stress of the early ICU experience 25 of 44 (61%). CONCLUSIONS Most patients and surrogates accept a deferred consent process for minimal risk research in the ICU. For appropriate ICU-based research, investigators and Institutional Review Boards should consider a deferred consent process if the subject lacks capacity and an appropriate surrogate is not readily available.
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Sole ML, Middleton A, Deaton L, Bennett M, Talbert S, Penoyer D. Enrollment Challenges in Critical Care Nursing Research. Am J Crit Care 2017; 26:395-400. [PMID: 28864436 DOI: 10.4037/ajcc2017511] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Enrollment challenges for critical care research are common. Contributing factors include short enrollment windows, the crisis nature of critical illness, lack of research staff, unavailable legal proxy, family dynamics, and language barriers. OBJECTIVE To describe enrollment statistics for an ongoing critical care nursing trial, barriers to recruitment, and strategies to enhance enrollment. METHODS Two years' worth of recruitment and enrollment data from an oral care intervention trial in critically ill adults receiving mechanical ventilation at 1 hospital were analyzed. Recruitment logs include number of patients screened, eligible, enrolled, and declined and patients' sex, race, and ethnicity. RESULTS Target enrollment (15.5 patients per month) was based on experience and historical data. Strategies implemented to promote enrollment included providing study personnel at least 18 hours per day for 7 days per week, regular rounds, communication with direct care staff, and Spanish consent processes. In 2 years, 6963 patients were screened; 1551 (22%) were eligible. Consent was sought from 366 (24% of eligible patients). Enrollment averaged 13.3 patients per month (86% of projected target). The main factor impeding enrollment was unavailability of a legal proxy to provide consent (88%). The refusal rates of white (11%), black (13%), and Hispanic (16%) patients did not differ significantly. However, those classified as Asian or as more than 1 race declined significantly more often (35%) than did white or black patients (P = .02). CONCLUSIONS Unavailability of a legal proxy within a short enrollment window was the major challenge to enrollment. Various factors influenced consent decisions. Clinical study design requires more conservative estimates.
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Affiliation(s)
- Mary Lou Sole
- Mary Lou Sole is dean and professor and holds the Orlando Health Endowed Chair in Nursing at the University of Central Florida College of Nursing, Orlando, Florida. Aurea Middleton and Lara Deaton are clinical research coordinators and Melody Bennett is the study project coordinator, Orlando Health, Orlando, Florida. Steven Talbert is a clinical assistant professor with the University of Central Florida, Orlando, Florida. Daleen Penoyer is director, Center for Nursing Research and Advanced Practice Nursing, Orlando Health.
| | - Aurea Middleton
- Mary Lou Sole is dean and professor and holds the Orlando Health Endowed Chair in Nursing at the University of Central Florida College of Nursing, Orlando, Florida. Aurea Middleton and Lara Deaton are clinical research coordinators and Melody Bennett is the study project coordinator, Orlando Health, Orlando, Florida. Steven Talbert is a clinical assistant professor with the University of Central Florida, Orlando, Florida. Daleen Penoyer is director, Center for Nursing Research and Advanced Practice Nursing, Orlando Health
| | - Lara Deaton
- Mary Lou Sole is dean and professor and holds the Orlando Health Endowed Chair in Nursing at the University of Central Florida College of Nursing, Orlando, Florida. Aurea Middleton and Lara Deaton are clinical research coordinators and Melody Bennett is the study project coordinator, Orlando Health, Orlando, Florida. Steven Talbert is a clinical assistant professor with the University of Central Florida, Orlando, Florida. Daleen Penoyer is director, Center for Nursing Research and Advanced Practice Nursing, Orlando Health
| | - Melody Bennett
- Mary Lou Sole is dean and professor and holds the Orlando Health Endowed Chair in Nursing at the University of Central Florida College of Nursing, Orlando, Florida. Aurea Middleton and Lara Deaton are clinical research coordinators and Melody Bennett is the study project coordinator, Orlando Health, Orlando, Florida. Steven Talbert is a clinical assistant professor with the University of Central Florida, Orlando, Florida. Daleen Penoyer is director, Center for Nursing Research and Advanced Practice Nursing, Orlando Health
| | - Steven Talbert
- Mary Lou Sole is dean and professor and holds the Orlando Health Endowed Chair in Nursing at the University of Central Florida College of Nursing, Orlando, Florida. Aurea Middleton and Lara Deaton are clinical research coordinators and Melody Bennett is the study project coordinator, Orlando Health, Orlando, Florida. Steven Talbert is a clinical assistant professor with the University of Central Florida, Orlando, Florida. Daleen Penoyer is director, Center for Nursing Research and Advanced Practice Nursing, Orlando Health
| | - Daleen Penoyer
- Mary Lou Sole is dean and professor and holds the Orlando Health Endowed Chair in Nursing at the University of Central Florida College of Nursing, Orlando, Florida. Aurea Middleton and Lara Deaton are clinical research coordinators and Melody Bennett is the study project coordinator, Orlando Health, Orlando, Florida. Steven Talbert is a clinical assistant professor with the University of Central Florida, Orlando, Florida. Daleen Penoyer is director, Center for Nursing Research and Advanced Practice Nursing, Orlando Health
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Dotolo D, Nielsen EL, Curtis JR, Engelberg RA. Strategies for Enhancing Family Participation in Research in the ICU: Findings From a Qualitative Study. J Pain Symptom Manage 2017; 54:226-230.e1. [PMID: 28438584 PMCID: PMC5557665 DOI: 10.1016/j.jpainsymman.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/23/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022]
Abstract
CONTEXT Family members of critically ill patients who participate in research focused on palliative care issues have been found to be systematically different from those who do not. These differences threaten the validity of research and raise ethical questions about worsening disparities in care by failing to represent diverse perspectives. OBJECTIVES This study's aims were to explore: 1) barriers and facilitators influencing family members' decisions to participate in palliative care research; and 2) potential methods to enhance research participation. METHODS Family members who were asked to participate in a randomized trial testing the efficacy of a facilitator to improve clinician-family communication in the intensive care unit (ICU). Family members who participated (n = 17) and those who declined participation (n = 7) in Family Communication Study were interviewed about their recruitment experiences. We also included family members of currently critically ill patients to assess current experiences (n = 4). Interviews were audio-recorded and transcribed. Investigators used thematic analysis to identify factors influencing family members' decisions. Transcripts were co-reviewed to synthesize codes and themes. RESULTS Three factors influencing participants' decisions were identified: Altruism, Research Experience, and Enhanced Resources. Altruism and Research Experience described intrinsic characteristics that are less amenable to strategies for improving participation rates. Enhanced Resources reflects families' desires for increased access to information and logistical and emotional support. CONCLUSION Family members found their recruitment experiences to be positive when staff were knowledgeable about the ICU, sensitive to the stressful circumstances, and conveyed a caring attitude. By training research staff to be supportive of families' emotional needs and need for logistical knowledge about the ICU, recruitment of a potentially more diverse sample of families may be enhanced.
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Affiliation(s)
- Danae Dotolo
- School of Social Work, University of Washington, Seattle, Washington, USA.
| | - Elizabeth L Nielsen
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
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Turnbull AE, Hashem MD, Rabiee A, To A, Chessare CM, Needham DM. Evaluation of a strategy for enrolling the families of critically ill patients in research using limited human resources. PLoS One 2017; 12:e0177741. [PMID: 28542632 PMCID: PMC5444627 DOI: 10.1371/journal.pone.0177741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/02/2017] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Clinical trials of interventions aimed at the families of intensive care unit (ICU) patients have proliferated but recruitment for these trials can be challenging. OBJECTIVES To evaluate a strategy for recruiting families of patients currently being treated in an ICU using limited human resources and time-varying daily screening over 7 consecutive days. METHODS We screened the Johns Hopkins Hospital medical ICU census 7 days per week to identify eligible family members. We then made daily, in-person attempts to enroll eligible families during a time-varying 2-hour enrollment period until families declined participation, consented, or were no longer eligible. MEASUREMENTS AND MAIN RESULTS The primary outcome was the proportion of eligible patients for whom ≥1 family member was enrolled. Secondary outcomes included enrollment of legal healthcare proxies, the consent rate among families approached for enrollment, and success rates for recruiting at different times during the day and week. Among 284 eligible patients, 108 (38%, 95% CI 32%-44%) had ≥1 family member enrolled, and 75 (26%, 95% CI 21%-32%) had their legal healthcare proxy enrolled. Among 117 family members asked to participate, 108 (92%, 95% CI 86%-96%) were enrolled. Patients with versus without an enrolled proxy were more likely to be white (44% vs. 30%, P = .02), live in a zip code with a median income of ≥$100,000 (15% vs. 5%, P = .01), be mechanically ventilated (63% vs. 47%, P = .01), die in the ICU (19% vs. 9%, P = .03), and to have longer ICU stays (median 5.0 vs. 1.8 days, P<.001). Day of the week and time of day were not associated with family presence in the ICU or consent rate. CONCLUSIONS Family members were recruited for more than one third of eligible patients, and >90% of approached consented to participate. There are important demographic differences between patients with vs without an enrolled family member.
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Affiliation(s)
- Alison E. Turnbull
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Mohamed D. Hashem
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Cleveland Clinic, Department of Medicine, Cleveland, Ohio, United States of America
| | - Anahita Rabiee
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - An To
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Caroline M. Chessare
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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Patient Eligibility for Randomized Controlled Trials in Critical Care Medicine: An International Two-Center Observational Study. Crit Care Med 2017; 45:216-224. [PMID: 27779514 DOI: 10.1097/ccm.0000000000002061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We conducted this study to determine the generalizability of information gained from randomized controlled trials in critically ill patients by assessing the incidence of eligibility for each trial. DESIGN Prospective, observational cohort study. We identified the 15 most highly cited randomized controlled trials in critical care medicine published between 1998 and 2008. We examined the inclusion and exclusion criteria for each randomized controlled trial and then assessed the eligibility of each patient admitted to a study ICU for each randomized controlled trial and calculated rates of potential trial eligibility in the cohort. SETTING Three ICUs in two academic medical centers in Canada and the United States. PATIENTS Adults admitted to participating medical or surgical ICU in November 2010 or July 2011. MEASUREMENTS AND MAIN RESULTS Among the 15 trials, the most common trial inclusion criteria were clinical criteria for sepsis (six trials) or acute respiratory distress syndrome (four trials), use of invasive mechanical ventilation (five trials) or related to ICU type or duration of ICU stay (five trials). Of the 93 patients admitted to a study ICU, 52% of patients (n = 48) did not meet enrollment criteria for any studied randomized controlled trial and 30% (n = 28) were eligible for only one of the 15. Trial ineligibility was mostly due to failure to meet inclusion criteria (87% of screening assessments) rather than meeting specific exclusion criteria (52% of screening assessments). Of the positive screening assessments, 85% occurred on the first day of ICU admission. CONCLUSIONS Slightly more than half of the patients assessed were not eligible for enrollment in any of 15 major randomized controlled trials in critical care, most often due to the absence of the specific clinical condition of study. The majority of patients who met criteria for a randomized controlled trial did so on the first day of ICU admission.
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Marshall AP, Lemieux M, Dhaliwal R, Seyler H, MacEachern KN, Heyland DK. Novel, Family-Centered Intervention to Improve Nutrition in Patients Recovering From Critical Illness: A Feasibility Study. Nutr Clin Pract 2017; 32:392-399. [PMID: 28537514 DOI: 10.1177/0884533617695241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Critically ill patients are at increased risk of developing malnutrition-related complications because of physiological changes, suboptimal delivery, and reduced intake. Strategies to improve nutrition during critical illness recovery are required to prevent iatrogenic underfeeding and risk of malnutrition. The purpose of this study was to assess the feasibility and acceptability of a novel family-centered intervention to improve nutrition in critically ill patients. MATERIALS AND METHODS A 3-phase, prospective cohort feasibility study was conducted in 4 intensive care units (ICUs) across 2 countries. Intervention feasibility was determined by patient eligibility, recruitment, and retention rates. The acceptability of the intervention was assessed by participant perspectives collected through surveys. Participants included family members of the critically ill patients and ICU and ward healthcare professionals (HCPs). RESULTS A total of 75 patients and family members, as well as 56 HCPs, were enrolled. The consent rate was 66.4%, and 63 of 75 (84%) of family participants completed the study. Most family members (53/55; 98.1%) would recommend the nutrition education program to others and reported improved ability to ask questions about nutrition (16/20; 80.0%). Family members viewed nutrition care more positively in the ICU. HCPs agreed that families should partner with HCPs to achieve optimal nutrition in the ICU and the wards. Health literacy was identified as a potential barrier to family participation. CONCLUSION The intervention was feasible and acceptable to families of critically ill patients and HCPs. Further research to evaluate intervention impact on nutrition intake and patient-centered outcomes is required.
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Affiliation(s)
- Andrea P Marshall
- 1 National Health and Medical Research Council Centre for Research Excellence in Nursing Interventions for Hospitalised Patients, School of Nursing and Midwifery, Menzies Health Institute, Griffith University and Gold Coast Health, Southport, Queensland, Australia
| | - Margot Lemieux
- 2 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Rupinder Dhaliwal
- 2 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,3 Metabolic Syndrome Canada, Kingston, Ontario, Canada
| | - Hilda Seyler
- 4 Clinical Nutrition and Food Services, Halton Healthcare, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Kristen N MacEachern
- 5 Clinical Nutrition and Critical Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daren K Heyland
- 6 Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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van Beinum A, Hornby L, Dhanani S, Ward R, Chambers-Evans J, Menon K. Feasibility of conducting prospective observational research on critically ill, dying patients in the intensive care unit. JOURNAL OF MEDICAL ETHICS 2017; 43:47-51. [PMID: 27738255 DOI: 10.1136/medethics-2016-103683] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/20/2016] [Accepted: 08/31/2016] [Indexed: 05/25/2023]
Abstract
Studying patients during the end of life is important, as it has the potential to lead to improvements in care for the dying. For patients who die after a controlled withdrawal of life-sustaining therapies in the intensive care unit, information about the natural history of death and the process of removing life support has additionally led to advances in practice for deceased organ donation. However, this unique population of severely critically ill and imminently dying patients has been difficult to study, largely due to assumptions made by research teams and ethics boards alike about the logistical difficulties of obtaining consent and completing research procedures before or during the process of withdrawal of life-sustaining therapies. In this paper, we describe the ethics substudy of the first prospective observational research study in Canada to obtain consent and collect clinical data on patients during the process of withdrawal of life-sustaining therapies in the intensive care unit. We describe in detail the process of protocol development, review by five institutional research ethics boards and bedside staff satisfaction with the study. We conclude that prospective research on a critically ill and imminently dying population is feasible and can be conducted in an ethical manner. Further information is needed about the experiences and motivations of families and substitute decision makers who provide consent for research on critically ill intensive care unit patients at the end of life.
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Affiliation(s)
- Amanda van Beinum
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Laura Hornby
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada
| | - Sonny Dhanani
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Roxanne Ward
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Jane Chambers-Evans
- McGill University Health Centre (retired), Montreal, Canada
- Ingram School of Nursing, McGill University, Montreal, Canada
| | - Kusum Menon
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
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Honarmand K, Belley-Cote EP, Ulic D, Khalifa A, Gibson A, McClure G, Savija N, Alshamsi F, D'Aragon F, Rochwerg B, Duan EH, Karachi T, Lamontagne F, Devereaux PJ, Whitlock RP, Cook DJ. The Deferred Consent Model in a Prospective Observational Study Evaluating Myocardial Injury in the Intensive Care Unit. J Intensive Care Med 2016; 33:475-480. [PMID: 29991343 DOI: 10.1177/0885066616680772] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Informed consent is a hallmark of ethical clinical research. An inherent challenge in critical care research is obtaining consent when patients lack decision-making capacity. One solution is deferred consent, which is often used for studies that are low risk or involve emergency interventions. Our objective was to describe a deferred consent model in a low-risk critical care study. METHODS Prognostic Value of Elevated Troponins in Critical Illness Study was a prospective, pilot observational study of critically ill patients in 3 intensive care units, involving serial electrocardiograms and cardiac biomarkers. Newly admitted patients were enrolled over 1 month. When possible, informed consent was obtained a priori from the patient or substitute decision maker (SDM); otherwise, consent was deferred until the patient regained consent capacity or until their SDM was available. Logistic regression analysis was used to determine the association between patient's sex, Acute Physiology and Chronic Health Evaluation II score, study center, person providing consent (patient vs SDM), method of consent (telephone vs in person), and the provision or not of informed consent. RESULTS The overall consent rate was 80.1% (213 of 266 persons approached). Of the 53 persons declining consent, 37 (69.8%) agreed to the use of data collected up until that point. Over half of all consent encounters were with patients rather than SDMs. Median interval delay between enrollment and the consent encounter was 1 day. On multivariate analysis, the only variable associated with consent was male sex of the patient (odds ratio for males 2.59, confidence interval: 1.19-5.63). CONCLUSION Deferred consent facilitates implementation of time-sensitive research protocols until a consent encounter is possible. As a feasible alternative to exclusive a priori consent, the deferred consent model can be useful in low-risk studies in critically ill patients.
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Affiliation(s)
- Kimia Honarmand
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Cote
- 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,3 Population Health Research Institute, Hamilton, Ontario, Canada
| | - Diana Ulic
- 4 Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Abubaker Khalifa
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Gibson
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Graham McClure
- 5 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nevena Savija
- 3 Population Health Research Institute, Hamilton, Ontario, Canada
| | - Fayez Alshamsi
- 6 Department of Internal Medicine, College of Medicine & Health Sciences, UAE University, Al Ain, United Arab Emirates
| | - Frederick D'Aragon
- 7 Department of Anesthesia, Université de Sherbrooke, Sherbrooke, Québec, Canada.,8 Centre de recherche du Centre hospitalier, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Bram Rochwerg
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Erick H Duan
- 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - François Lamontagne
- 8 Centre de recherche du Centre hospitalier, Université de Sherbrooke, Sherbrooke, Québec, Canada.,9 Department of Medicine, Université de Sherbrooke, Québec, Canada
| | - P J Devereaux
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,5 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard P Whitlock
- 5 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,10 Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Perspective on optimizing clinical trials in critical care: how to puzzle out recurrent failures. J Intensive Care 2016; 4:67. [PMID: 27826449 PMCID: PMC5097421 DOI: 10.1186/s40560-016-0191-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/26/2016] [Indexed: 12/13/2022] Open
Abstract
Background Critical care is a complex field of medicine, especially because of its diversity and unpredictability. Mortality rates of the diseases are usually high and patients are critically ill, admitted in emergency, and often have several overlapping diseases. This makes research in critical care also complex because of patients’ conditions and because of the numerous ethical and regulatory requirements and increasing global competition. Many clinical trials in critical care have thus failed and almost no drug has yet been developed to treat intensive care unit (ICU) patients. Learning from the failures, clinical trials must now be optimized. Main body Several aspects can be improved, beginning with the design of studies that should take into account patients’ diversity in the ICU. At the site level, selection should reflect more accurately the potential of recruitment. Management of all players that can be involved in the research at a site level should be a priority. Moreover, training should be offered to all staff members, including the youngest. National and international networks are also part of the future as they create a collective synergy potentially improving the efficacy of sites. Finally, computerization is another area that must be further developed with the appropriate tools. Conclusion Clinical research in the ICU is thus a discipline in its own right that still requires tailored approaches. Changes have to be initiated by the investigators themselves as they know all the specificities of the field.
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Pattison N, Arulkumaran N, Humphreys S, Walsh T. Exploring obstacles to critical care trials in the UK: A qualitative investigation. J Intensive Care Soc 2016; 18:36-46. [PMID: 28979535 DOI: 10.1177/1751143716663749] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical trials in critical care are often resource-intense, with many unique challenges. Barriers to effective recruitment and implementation of study intervention have not been explored in a UK context. AIM To identify facilitating factors and barriers to enrolling patients into critical care clinical trials within the UK from clinician's perspectives. METHODS A qualitative interview study was undertaken on behalf of the National Institute of Health Research critical care specialty group, in which research active clinicians across different Clinical Research Networks were interviewed. A loosely structured interview schedule was used, based on themes generated from the literature associated with accessing critical care trials. Research teams (critical care doctors, research nurses, and trial coordinators) from hospitals from each Clinical Research Network were contacted to try to achieve representation across the UK. RESULTS Interviews were carried out across nine UK Clinical Research Networks with a range of doctors and research nurses. All hospitals were teaching hospitals with varying research nurse numbers and allocated consultant research sessions. There were a range of six to nine ongoing clinical trials in critical care for each centre representative interviewed. Data were analysed using framework analysis, and six final themes were identified related to factors associated with: centre, unit, resources, study, clinician, and patient/family. The most commonly cited barrier to conducting clinical trials was related to resources, namely insufficient human and financial resources, leading to staff and study recruitment difficulties. Clinical uncertainty and equipoise regarding comparative merits of trials were challenging in terms of engaging critical care teams. A number of patient and family factors added complexities in terms of recruitment; however, refusal rates were generally reported as low. CONCLUSION Flexibility in funding and employment by research teams enables continuity of studies and staff. Innovative measures to incentivise research nurses and clinical teams can help recruit more patients into trials. Research teams are highly committed to providing cover to recruit critical care trials, and a significant effort to anticipate barriers is undertaken; these endeavours are summarised to provide guidance for other teams wishing to address any potential difficulties.
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Affiliation(s)
- Natalie Pattison
- Critical Care, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Sally Humphreys
- Critical Care, West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
| | - Tim Walsh
- Critical Care, University of Edinburgh/Edinburgh Royal Infirmary, Edinburgh, UK
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Schmidt K, Worrack S, Von Korff M, Davydow D, Brunkhorst F, Ehlert U, Pausch C, Mehlhorn J, Schneider N, Scherag A, Freytag A, Reinhart K, Wensing M, Gensichen J, for the SMOOTH Study Group. Effect of a Primary Care Management Intervention on Mental Health-Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. JAMA 2016; 315:2703-11. [PMID: 27367877 PMCID: PMC5122319 DOI: 10.1001/jama.2016.7207] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Survivors of sepsis face long-term sequelae that diminish health-related quality of life and result in increased care needs in the primary care setting, such as medication, physiotherapy, or mental health care. OBJECTIVE To examine if a primary care-based intervention improves mental health-related quality of life. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted between February 2011 and December 2014, enrolling 291 patients 18 years or older who survived sepsis (including septic shock), recruited from 9 intensive care units (ICUs) across Germany. INTERVENTIONS Participants were randomized to usual care (n = 143) or to a 12-month intervention (n = 148). Usual care was provided by their primary care physician (PCP) and included periodic contacts, referrals to specialists, and prescription of medication, other treatment, or both. The intervention additionally included PCP and patient training, case management provided by trained nurses, and clinical decision support for PCPs by consulting physicians. MAIN OUTCOMES AND MEASURES The primary outcome was change in mental health-related quality of life between ICU discharge and 6 months after ICU discharge using the Mental Component Summary (MCS) of the 36-Item Short-Form Health Survey (SF-36 [range, 0-100; higher ratings indicate lower impairment; minimal clinically important difference, 5 score points]). RESULTS The mean age of the 291 patients was 61.6 years (SD, 14.4); 66.2% (n = 192) were men, and 84.4% (n = 244) required mechanical ventilation during their ICU stay (median duration of ventilation, 12 days [range, 0-134]). At 6 and 12 months after ICU discharge, 75.3% (n = 219 [112 intervention, 107 control]) and 69.4% (n = 202 [107 intervention, 95 control]), respectively, completed follow-up. Overall mortality was 13.7% at 6 months (40 deaths [21 intervention, 19 control]) and 18.2% at 12 months (53 deaths [27 intervention, 26 control]). Among patients in the intervention group, 104 (70.3%) received the intervention at high levels of integrity. There was no significant difference in change of mean MCS scores (intervention group mean at baseline, 49.1; at 6 months, 52.9; change, 3.79 score points [95% CI, 1.05 to 6.54] vs control group mean at baseline, 49.3; at 6 months, 51.0; change, 1.64 score points [95% CI, -1.22 to 4.51]; mean treatment effect, 2.15 [95% CI, -1.79 to 6.09]; P = .28). CONCLUSIONS AND RELEVANCE Among survivors of sepsis and septic shock, the use of a primary care-focused team-based intervention, compared with usual care, did not improve mental health-related quality of life 6 months after ICU discharge. Further research is needed to determine if modified approaches to primary care management may be more effective. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN61744782.
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Affiliation(s)
- Konrad Schmidt
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Susanne Worrack
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Michael Von Korff
- Group Health Research Institute, Group Health Cooperative 1730 Minor Avenue, Suite 1600 Seattle, WA 98101, USA
| | - Dimitry Davydow
- Dpt. of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Box 356560 Seattle, WA 98195, USA
| | - Frank Brunkhorst
- Center of Clinical Studies, Dpt. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Salvador-Allende-Platz 27, 07747 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Ulrike Ehlert
- Dpt. of Psychology, University of Zuerich, Binzmuehlenstrasse 14, Box 26, CH-8050 Zuerich, Switzerland
| | - Christine Pausch
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Haertelstraβe 16-18, 04107 Leipzig, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Juliane Mehlhorn
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
| | - Nico Schneider
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
| | - André Scherag
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Antje Freytag
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
| | - Konrad Reinhart
- Dpt. of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Michel Wensing
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Radboud University Medical Centre, Radboud Institute of Health Sciences, Geert Grooteplein 9, PO Box 9101, 6500 HB Nijmegen, Netherlands
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
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Schandelmaier S, von Elm E, You JJ, Blümle A, Tomonaga Y, Lamontagne F, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Sun X, Bassler D, Busse JW, Ferreira-González I, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Cook DJ, Meade MO, Bucher HC, Kasenda B, Briel M. Premature Discontinuation of Randomized Trials in Critical and Emergency Care: A Retrospective Cohort Study. Crit Care Med 2016; 44:130-7. [PMID: 26468895 DOI: 10.1097/ccm.0000000000001369] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Randomized clinical trials that enroll patients in critical or emergency care (acute care) setting are challenging because of narrow time windows for recruitment and the inability of many patients to provide informed consent. To assess the extent that recruitment challenges lead to randomized clinical trial discontinuation, we compared the discontinuation of acute care and nonacute care randomized clinical trials. DESIGN Retrospective cohort of 894 randomized clinical trials approved by six institutional review boards in Switzerland, Germany, and Canada between 2000 and 2003. SETTING Randomized clinical trials involving patients in an acute or nonacute care setting. SUBJECTS AND INTERVENTIONS We recorded trial characteristics, self-reported trial discontinuation, and self-reported reasons for discontinuation from protocols, corresponding publications, institutional review board files, and a survey of investigators. MEASUREMENTS AND MAIN RESULTS Of 894 randomized clinical trials, 64 (7%) were acute care randomized clinical trials (29 critical care and 35 emergency care). Compared with the 830 nonacute care randomized clinical trials, acute care randomized clinical trials were more frequently discontinued (28 of 64, 44% vs 221 of 830, 27%; p = 0.004). Slow recruitment was the most frequent reason for discontinuation, both in acute care (13 of 64, 20%) and in nonacute care randomized clinical trials (7 of 64, 11%). Logistic regression analyses suggested the acute care setting as an independent risk factor for randomized clinical trial discontinuation specifically as a result of slow recruitment (odds ratio, 4.00; 95% CI, 1.72-9.31) after adjusting for other established risk factors, including nonindustry sponsorship and small sample size. CONCLUSIONS Acute care randomized clinical trials are more vulnerable to premature discontinuation than nonacute care randomized clinical trials and have an approximately four-fold higher risk of discontinuation due to slow recruitment. These results highlight the need for strategies to reliably prevent and resolve slow patient recruitment in randomized clinical trials conducted in the critical and emergency care setting.
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Affiliation(s)
- Stefan Schandelmaier
- 1Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland.2Department of Medicine, Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland.3Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.4Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.5Department of Medicine, McMaster University, Hamilton, Ontario, Canada.6German Cochrane Centre, Medical Center-University of Freiburg, Freiburg, Germany.7Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.8Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Canada.9Department of Health and Society, Austrian Federal Institute for Health Care, Vienna, Austria.10Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.11Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.12Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile.13Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, Ontario, Canada.14Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.15Department of Medicine, State University of New York at Buffalo, Buffalo, NY.16Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.17Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.18Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.19Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada.20Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidem
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Arabi YM, Cook DJ, Zhou Q, Smith O, Hand L, Turgeon AF, Matte A, Mehta S, Graham R, Brierley K, Adhikari NKJ, Meade MO, Ferguson ND. Characteristics and Outcomes of Eligible Nonenrolled Patients in a Mechanical Ventilation Trial of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2016; 192:1306-13. [PMID: 26192398 DOI: 10.1164/rccm.201501-0172oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Patients eligible for randomized controlled trials may not be enrolled for various reasons. Nonenrollment may affect study generalizability and lengthen the time required for trial completion. OBJECTIVES To describe characteristics and outcomes of eligible nonenrolled (ENE) patients in a multicenter trial of mechanical ventilation strategies. METHODS Within the OSCILLATE trial of high-frequency oscillation (HFO) versus conventional ventilation (CV) in adults with adult respiratory distress syndrome, and with approval from research ethics boards, we collected a minimal dataset on patients who satisfied eligibility criteria but were not enrolled. We categorized ENE patients as ENE-HFO and ENE-CV based on receipt of HFO at any time. We used multivariable logistic regression to assess the association between ENE status and mortality. MEASUREMENTS AND MAIN RESULTS A total of 548 patients were randomized, and 546 were ENE. The most common reasons for ENE were no consent (42%), physician refusal (24%), missed randomization window (15%), and current HFO use (14%). Compared with randomized patients in respective arms of the trial, ENE-HFO patients were younger and had worse lung injury, whereas ENE-CV patients had lower illness severity. ENE status was independently associated with mortality (adjusted odds ratio, 1.39; 95% confidence interval, 1.06-1.84; P = 0.02), with no significant interaction with ventilation treatment group. CONCLUSIONS Nonenrollment was common, with approximately one ENE patient for every randomized patient. Our study suggests that enrollment in trials of mechanical ventilation may be associated with improved outcomes compared with standard care and highlights the need for prospective tracking and transparent reporting of ENE patients as part of trial management.
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Affiliation(s)
- Yaseen M Arabi
- 1 Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Deborah J Cook
- 2 Department of Medicine and.,3 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Qi Zhou
- 3 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Orla Smith
- 4 Critical Care Department & Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Lori Hand
- 3 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Alexis F Turgeon
- 5 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and.,6 Population Health and Optimal Health Practices Research Unit, Research Center of the CHU de Québec, Université Laval, Québec City, Québec, Canada
| | | | - Sangeeta Mehta
- 8 Interdepartmental Division of Critical Care Medicine.,13 Department of Medicine
| | | | - Kristin Brierley
- 15 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Neill K J Adhikari
- 8 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Maureen O Meade
- 2 Department of Medicine and.,3 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Niall D Ferguson
- 7 University Health Network, Toronto, Canada.,10 Memorial Hermann, Texas Medical Center, Houston, Texas.,11 University of Michigan Health System, Ann Arbor, Michigan.,12 Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Canada; and.,16 Division of Respirology, Department of Medicine, Mount Sinai Hospital, Toronto, Canada
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Jeffs E, Vollam S, Young JD, Horsington L, Lynch B, Watkinson PJ. Wearable monitors for patients following discharge from an intensive care unit: practical lessons learnt from an observational study. J Adv Nurs 2016; 72:1851-62. [PMID: 26990704 DOI: 10.1111/jan.12959] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 11/29/2022]
Abstract
AIMS To identify the practical challenges encountered when using wearable monitors for patients discharged from the intensive care unit. BACKGROUND Patients discharged from intensive care units are a high-risk group that might benefit from continuing observation using 'wearable' monitors to enable faster identification of physiological deterioration and facilitate timely clinical action. This area of technological innovation is of key interest to nurses who manage this group of patients. DESIGN A prospective observational study. METHODS An observational study conducted in 2013-2014 used wearable monitors to record continuous observations for patients discharged from an intensive care unit to develop a predictive model of patients likely to deteriorate. Screening data for study eligibility and case report form data to assess monitor tolerance and comfort were collected daily and analysed using Microsoft Access. RESULTS/FINDINGS Patients (n = 2704) were discharged from an intensive care unit during the study, 208 consented to wearing the monitor. Of the 192 included in analysis, 130 (67·7%) removed the monitor before the trial finished. Reasons cited for removal included 'discomfort and irritation' 61 (31·8%) and 'feeling too unwell' 8 (4·2%). Five hundred seventeen patients were screened following adaption of the wearable monitor. Despite design changes, 56 (10·8%) patients were unable to wear monitors for reasons related to their anatomy or condition. Of 124 patients, 65 patients (52·4%) who were approached refused participation. CONCLUSION Work is needed to understand wireless monitor comfort and design for acutely unwell patients. Product design needs to develop further, so patients are catered for in flexibility of monitor placement and improved comfort for long-term wear.
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Affiliation(s)
- Emma Jeffs
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Trust, Oxford, UK
| | - Lois Horsington
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Breda Lynch
- Oxford University Hospitals NHS Trust, Oxford, UK
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Garde A, O'Hearn K, Nicholls S, Menon K. Reporting of consent rates in critical care studies: room for improvement. J Clin Epidemiol 2015; 74:51-6. [PMID: 26677982 DOI: 10.1016/j.jclinepi.2015.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/11/2015] [Accepted: 11/05/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Reporting of consent rates in published articles is important to determine potential sources of bias and validity and generalizability of results. Our objective was to determine the percentage of critical care studies for which the consent rate was reported. STUDY DESIGN AND SETTING We reviewed all articles published in eight medical journals in 2013. Studies meeting the following inclusion criteria were selected: (1) randomized controlled trial (RCT) or observational clinical study, (2) study population involving critically ill patients, and (3) part of the study occurring in an intensive care unit. RESULTS A total of 1,871 articles were screened of which 156 were included. The consent rate was discernable in 30.8% of articles (48/156, 95% confidence interval: 24.1, 38.4) with a median consent rate of 86.9% (interquartile range, 71.6, 94.1). A statement on Research Ethics Board approval was included in 96.8% of studies. There was a significant difference in reporting of consent rates between RCTs and non-RCTs (58.70% vs. 19.09%, P < 0.0001). CONCLUSION Consent rates are reported in less than one-third of critical care studies. We encourage journals to require reporting of consent rates to improve interpretation, validity, and generalizability of critical care study results.
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Affiliation(s)
- Avanti Garde
- University of Ottawa, 75 Laurier Ave E, Ottawa, Ontario K1N 6N5, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Research Building 2, 2nd Floor, Room 2119, Ottawa, Ontario K1H 8L1, Canada
| | - Stuart Nicholls
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Research Building 2, 2nd Floor, Room 2119, Ottawa, Ontario K1H 8L1, Canada
| | - Kusum Menon
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada.
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Marshall AP, Wake E, Weisbrodt L, Dhaliwal R, Spencer A, Heyland DK. A multi-faceted, family-centred nutrition intervention to optimise nutrition intake of critically ill patients: The OPTICS feasibility study. Aust Crit Care 2015; 29:68-76. [PMID: 26603213 DOI: 10.1016/j.aucc.2015.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Critically ill patients are at risk of developing malnutrition which contributes to functional decline and hospital re-admission. Strategies to promote nutritional intake have had a modest effect on protein-calorie intake. None have addressed the recovery trajectory of critical illness or incorporated family as advocates. OBJECTIVES We evaluated the feasibility and acceptability of a family-centred intervention designed to optimise nutrition during and following recovery from critical illness. DESIGN A prospective cohort study. SETTING Two Australian adult intensive care units. PARTICIPANTS A convenience sample of 49 patients and their families was recruited. Patients ≥18 years of age anticipated to require mechanical ventilation for at least 2 days were eligible, provided their family visited regularly and were able to communicate in English. Health care professionals including doctors (n=4), nurses (n=20) and dietitians (n=2) also participated. METHODS Demographic data were obtained from participants. Recruitment and retention informed study feasibility. Individual and group interviews informed participant views on the acceptability, perception of and experience with the intervention. Inductive analysis was used to analyse qualitative data. RESULTS 187 (15.8%) patients met the eligibility criteria; 49 patients and 51 family members consented to participate for a 20.3% consent failure rate. We interviewed 33 (67.3%) family members and 13 (43.4%) patients, all of whom considered the intervention acceptable and who would participate in a similar intervention again, given the opportunity. Inductive analysis of qualitative data from all participants identified three themes: variability in in-hospital nutrition support, families as advocates for optimal nutrition, and partnering with health care providers. CONCLUSION We described a feasible and acceptable family centred intervention that may be effective in promoting nutrition intake in critically ill patients. Further research is required to examine contextual factors impacting implementation of family-centred interventions, particularly those that involve active family participation and advocacy.
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Affiliation(s)
- Andrea P Marshall
- NHMRC Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University and Gold Coast Health, Australia; Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | - Elizabeth Wake
- Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | | | | | - Alan Spencer
- Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, 76 Stuart Street, Suite 5-416, Kingston, Ontario, Canada K7L 2V7; Queen's University, 99 University Avenue, Kingston, Ontario, Canada K7L 3N6.
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Eikelboom JW, Cook RJ, Barty R, Liu Y, Arnold DM, Crowther MA, Devereaux PJ, Ellis M, Figueroa P, Gallus A, Hirsh J, Kurz A, Roxby D, Sessler DI, Sharon Y, Sobieraj-Teague M, Warkentin TE, Webert KE, Heddle NM. Rationale and Design of the Informing Fresh versus Old Red Cell Management (INFORM) Trial: An International Pragmatic Randomized Trial. Transfus Med Rev 2015; 30:25-9. [PMID: 26651419 DOI: 10.1016/j.tmrv.2015.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 11/15/2022]
Abstract
Although red blood cell transfusion is a potentially lifesaving intervention in severely anemic and acutely bleeding patients, some observational studies have suggested that prolonged red cell storage before transfusion is associated with harm. INFORM is a large, pragmatic, randomized controlled trial comparing the effect of the shorter storage with longer storage red blood cell transfusions on inhospital mortality in hospitalized patients who require a blood transfusion. The trial is being conducted in centers in Australia, Canada, Israel, and the United States and is expected to enroll 31497 patients. If the results of INFORM indicate that shorter storage red blood cell transfusion is associated with superior outcomes compared with standard issue red blood cell transfusion, consideration may be given to shortening blood storage times. If, in contrast, the INFORM trial provides no evidence of harm from longer storage red blood cells, clinicians and patients may be reassured that current blood inventory management strategies are appropriate.
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Affiliation(s)
- John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Rebecca Barty
- Transfusion Medicine Program, McMaster University, Hamilton, ON, Canada
| | - Yang Liu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Hamilton, ON, Canada
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | - Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrea Kurz
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | | | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | | | | | - Theodore E Warkentin
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Kathryn E Webert
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Hamilton, ON, Canada
| | - Nancy M Heddle
- Transfusion Medicine Program, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Hamilton, ON, Canada
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Clarridge BR, Bolcic-Jankovic D, LeBlanc J, Mahmood RS, Kennedy CR, Freeman BD. Does difficulty functioning in the surrogate role equate to vulnerability in critical illness research? Use of path analysis to examine the relationship between difficulty providing substituted judgment and receptivity to critical illness research participation. J Crit Care 2015; 30:1310-6. [PMID: 26304514 DOI: 10.1016/j.jcrc.2015.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/14/2015] [Accepted: 07/20/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Individuals who struggle to provide substitute judgment for the critically ill often find it challenging to engage in decision making for therapeutic interventions. Although essential to the conduct of research, how these individuals respond to requests for clinical trial participation is poorly understood. METHODS Survey data collected to examine surrogate attitudes toward research provided the conceptual framework to explore influences on decision making. Path analysis was used to derive the final model (nonlatent, fully recursive, 1 indicator/variable). RESULTS Surrogates with list-wise complete records (406) were analyzed. The following variables were not retained in the final model: education, income, religiosity, decision-making experience, discussion of patient's wishes, number of individuals assisting with decision making, trust in care providers, difficulty making decisions, and responsibility for decision making. Being white and having experience making treatment decisions for the patient during the current intensive care unit encounter affected the likelihood the surrogate would permit participation in research positively (parameter estimates, 0.281 and 0.06, respectively). No variable reflecting difficulty functioning in the surrogate role was associated with permitting research participation. CONCLUSIONS We were unable to demonstrate a relationship between perceived difficulty in decision making in the surrogate role and receptivity to clinical trial participation.
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Affiliation(s)
- Brian R Clarridge
- Center for Survey Research, University of Massachusetts-Boston, Boston, MA
| | | | - Jessica LeBlanc
- Center for Survey Research, University of Massachusetts-Boston, Boston, MA
| | - Rumel S Mahmood
- Center for Survey Research, University of Massachusetts-Boston, Boston, MA
| | - Carie R Kennedy
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Bradley D Freeman
- Department of Surgery, Washington University School of Medicine, St Louis, MO.
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75
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Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, Vriends M, de Vreede G, de Wilde RB, Serpa Neto A, Gama de Abreu M, Pelosi P, Schultz MJ. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials 2015; 16:226. [PMID: 26003545 PMCID: PMC4453265 DOI: 10.1186/s13063-015-0759-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 05/14/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is uncertain whether lung-protective mechanical ventilation using low tidal volumes should be used in all critically ill patients, irrespective of the presence of the acute respiratory distress syndrome (ARDS). A low tidal volume strategy includes use of higher respiratory rates, which could be associated with increased sedation needs, a higher incidence of delirium, and an increased risk of patient-ventilator asynchrony and ICU-acquired weakness. Another alleged side-effect of low tidal volume ventilation is the risk of atelectasis. All of these could offset the beneficial effects of low tidal volume ventilation as found in patients with ARDS. METHODS/DESIGN PReVENT is a national multicenter randomized controlled trial in invasively ventilated ICU patients without ARDS with an anticipated duration of ventilation of longer than 24 hours in 5 ICUs in The Netherlands. Consecutive patients are randomly assigned to a low tidal volume strategy using tidal volumes from 4 to 6 ml/kg predicted body weight (PBW) or a high tidal volume ventilation strategy using tidal volumes from 8 to 10 ml/kg PBW. The primary endpoint is the number of ventilator-free days and alive at day 28. Secondary endpoints include ICU and hospital length of stay (LOS), ICU and hospital mortality, the incidence of pulmonary complications, including ARDS, pneumonia, atelectasis, and pneumothorax, the cumulative use and duration of sedatives and neuromuscular blocking agents, incidence of ICU delirium, and the need for decreasing of instrumental dead space. DISCUSSION PReVENT is the first randomized controlled trial comparing a low tidal volume strategy with a high tidal volume strategy, in patients without ARDS at onset of ventilation, that recruits a sufficient number of patients to test the hypothesis that a low tidal volume strategy benefits patients without ARDS with regard to a clinically relevant endpoint. TRIAL REGISTRATION The trial is registered at www.clinicaltrials.gov under reference number NCT02153294 on 23 May 2014.
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Affiliation(s)
- Fabienne D Simonis
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Annemarije Braber
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - Harry P Gelissen
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands.
| | - Jeroen Heidt
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Gerard Innemee
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - Lotte M Steuten
- Department of Health Technology and Services Research, Twente University, Enschede, The Netherlands.
| | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands.
| | - Marijn Vriends
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | | | - Rob B de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy.
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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76
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Freeman BD, Bolcic-Jankovic D, Kennedy CR, LeBlanc J, Eastman A, Barillas J, Wittgen CM, Indsey K, Mahmood RS, Clarridge BR. Perspectives of Decisional Surrogates and Patients Regarding Critical Illness Genetic Research. AJOB Empir Bioeth 2015; 7:39-47. [PMID: 26752784 DOI: 10.1080/23294515.2015.1039148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Critical illness research is challenging due to disease severity and because patients are frequently incapacitated. Surrogates called upon to provide consent might not accurately represent patient preferences. Though commonplace, genetic data collection adds complexity in this context. We undertook this investigation to understand whether surrogate decision makers would be receptive to permitting participation in a critical illness genetics study and whether their decision making was consistent with that of the patient represented. METHODS We invited individuals identified as surrogates for critically ill adults, if required, as well as patients once recovered to participate in a survey designed to understand attitudes about genetic research. Associations between dependent (receptivity to participation, concordance of responses) and independent variables were tested using bivariate and multivariate logistic regression analyses. RESULTS Most of the entire surrogate sample (n=439) reported familiarity with research, including genetic research; tended to view research as useful; and were receptive to allowing their family member participate (with 39.6% and 38.1% stating that this would be "very" and "somewhat likely," respectively) even absent direct benefit. Willingness to participate was similar comparing genetic and non-genetic studies (χ2 [1,n=439]=0.00127, p=0.972), though respondents expressed worry regarding lack of confidentiality of genetic data. Responses were concordant in 70.8% of the 192 surrogate-patient pairs analyzed. In multivariate analysis, African American race was associated with less receptivity to genetic data collection (p<0.05). No factors associated with concordance of surrogate-patient response were identified. CONCLUSIONS Surrogates' receptivity to critical illness research was not influenced by whether the study entailed collection of genetic data. While more than two-thirds of surrogate-patient responses for participation in genetics research were concordant, concerns expressed regarding genetic data often related to breach of confidentiality. Emphasizing safeguards in place to minimize such breeches might prove an effective strategy for enhancing recruitment.
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77
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Affiliation(s)
- Gilda Cinnella
- Department of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy
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78
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Coenrollment in a randomized trial of high-frequency oscillation: prevalence, patterns, predictors, and outcomes*. Crit Care Med 2015; 43:328-38. [PMID: 25393702 DOI: 10.1097/ccm.0000000000000692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Enrollment of individual patients into more than one study has been poorly evaluated. The objective of this study was to describe the characteristics of patients, researchers and centers involved in coenrollment, studies precluding coenrollment, and the prevalence, patterns, predictors, and outcomes of coenrollment in a randomized clinical trial. DESIGN, SETTING, METHODS We conducted an observational study nested within the OSCILLation for Acute Respiratory Distress Syndrome Treated Early Trial, which compared high-frequency oscillatory ventilation to conventional ventilation. We collected patient, center, and study data on coenrollment in randomized patients. Multilevel regression examined factors independently associated with coenrollment, considering clustering within centers. We examined the effect of coenrollment on safety and the trial outcome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 127 of 548 randomized patients (23.2%) were coenrolled in 25 unique studies. Coenrollment was reported in 17 of 39 centers (43.6%). Patients were most commonly coenrolled in one additional randomized clinical trial (76; 59.8%). Coenrollment was less likely in older patients (odds ratio, 0.87; 95% CI, 0.76-0.997), and in ICUs with greater than 26 beds (odds ratio, 0.56; 95% CI, 0.34-0.94), and more likely by investigators with more than 11 years of experience (odds ratio, 1.73; 95% CI, 1.06-2.82), by research coordinators with more than 8 years of experience (odds ratio, 1.87; 95% CI, 1.11-3.18) and in Canada (odds ratio, 4.66; 95% CI, 1.43-15.15). Serious adverse events were similar between coenrolled high-frequency oscillatory ventilation and control patients. Coenrollment did not modify the treatment effect of high-frequency oscillatory ventilation on hospital mortality. CONCLUSIONS Coenrollment occurred in 23% of patients, commonly in younger patients, in smaller centers with more research infrastructure, and in Canada. Coenrollment did not influence patient safety or trial results.
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Hartog CS, Aneman A, Ricou B. Increasing participation in critical care studies: the need to understand surrogate decision-makers for critically ill patients. Intensive Care Med 2015; 41:345-7. [PMID: 25573498 DOI: 10.1007/s00134-014-3617-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/13/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Centre for Sepsis Care and Control, Jena University Hospital, 07747, Jena, Germany,
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Is there a role for physician involvement in introducing research to surrogate decision makers in the intensive care unit? (The Approach trial: a pilot mixed methods study). Intensive Care Med 2014; 41:58-67. [DOI: 10.1007/s00134-014-3558-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/09/2014] [Indexed: 11/26/2022]
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Cornu C, David F, Duchossoy L, Hansel-Esteller S, Bertoye PH, Giacomino A, Mouly S, Diebolt V, Blazejewski S. [Organising an investigation site: a national training reference document]. Therapie 2014; 69:367-81. [PMID: 24998702 DOI: 10.2515/therapie/2014029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/24/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Several surveys have shown a declining performance of French investigators in conducting clinical trials. This is partly due to insufficient and heterogeneous investigator training and site organisation. A multidisciplinary group was set up to propose solutions. We describe the tools developed to improve study site organisation. RESULTS This working group was made up of clinical research experts from academia, industry, drug regulatory authorities, general practice, and consulting. Methods and tools were developed to improve site organisation. CONCLUSIONS The proposed tools mainly focus on increasing investigators' awareness of their responsibilities, their research environment, the importance of a thorough feasibility analysis, and the implementation of active patient recruitment strategies. These tools should be able to improve site organisation and performances in conducting clinical trials.
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Affiliation(s)
- Catherine Cornu
- INSERM CIC201, CHU Lyon, Lyon, France - Service de Pharmacologie clinique, Lyon, France - Université de Lyon, UMR 5558, Lyon, France
| | - Frédérique David
- Assurance qualité et de la gouvernance médicale, Laboratoire GSK, Paris, France
| | - Luc Duchossoy
- Coordination des projets transverses, Laboratoire Sanofi, Paris, France
| | | | | | - Alain Giacomino
- Faculté de médecine de Tours ; Maison de santé pluri-professionnelle universitaire du Veron, Avoine, France
| | - Stéphane Mouly
- Université Paris Cité-Diderot, AP-HP, Hôpital Lariboisière, Paris, France
| | - Vincent Diebolt
- French-Clinical Research Infrastructures Network, Toulouse, France
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Deferred consent in a minimal-risk study involving critically ill subarachnoid hemorrhage patients. Can Respir J 2014; 21:293-6. [PMID: 24914705 DOI: 10.1155/2014/719270] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Alterations from first-party and surrogate decision-maker consent can enhance the feasibility of research involving critically ill patients. OBJECTIVE To describe the use of a deferred-consent model to enable participation of critically ill patients in a minimal-risk biomarker study. METHODS A prospective observational study was conducted in which serum biomarker samples were collected three times daily over the first 14 days following aneurysmal subarachnoid hemorrhage. Sample collection was initiated on intensive care unit admission and consent was obtained when research personnel could approach the patient or the patient's surrogate decision maker. RESULTS Twenty-seven patients were eligible for the study, of whom only five were capable of providing informed consent. Full consent was obtained for 21 (78%) patients through self- (n=4) and surrogate (n=17) consent. Partial consent or refusal (only permitting the collection of blood samples as a part of routine care or use of data) occurred in three patients. Among the 22 consents sought from surrogates, three (11%) refused participation. The refusals included the sickest patients in the cohort. Once consent was provided, no patient or surrogate withdrew consent before study completion. DISCUSSION Use of a deferred consent model enabled participation of critically ill patients in a minimal-risk biomarker study with no withdrawals. CONCLUSIONS Further research and enhanced awareness of the potential utility of hybrid models, including deferred consent in addition to patient or surrogate consent, in the conduct of low-risk and minimally interventional time-sensitive studies of critically ill patients are required.
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Physicians declining patient enrollment in clinical trials: what are the implications? Intensive Care Med 2013; 40:117-9. [PMID: 24253318 DOI: 10.1007/s00134-013-3151-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/30/2013] [Indexed: 01/14/2023]
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Matei M, Lemaire F. Intensive care unit research and informed consent: still a conundrum. Am J Respir Crit Care Med 2013; 187:1164-6. [PMID: 23725612 DOI: 10.1164/rccm.201303-0590ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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