CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials

Describing ICU data with tables

INTRODUCTION

The purpose of a scientific paper is to communicate results and within the paper this applies especially to the presentation of data. It is the universal practice in medical journals to present statistical results using tables. Good tables are an integral part of the manuscript. To help researchers communicate their results, we present practical guidance for reporting statistical results using tables.

RESULTS

Five key points are presented for reporting statistical results using tables: (1) early reflection and choice about the results to present, (2) presentation of tables and definition of rows and columns, (3) filling the cells, (4) title, caption, footnotes, and quality, (5) final checklist.

CONCLUSION

This guidance is a practical tool to improve the reporting of statistical results using tables when presenting ICU data in future research.

Effectiveness of a primary care-based intervention to reduce sitting time in overweight and obese patients (SEDESTACTIV): a randomized controlled trial; rationale and study design

BACKGROUND

There is growing evidence suggesting that prolonged sitting has negative effects on people's weight, chronic diseases and mortality. Interventions to reduce sedentary time can be an effective strategy to increase daily energy expenditure. The purpose of this study is to evaluate the effectiveness of a six-month primary care intervention to reduce daily of sitting time in overweight and mild obese sedentary patients.

METHOD/DESIGN

The study is a randomized controlled trial (RCT). Professionals from thirteen primary health care centers (PHC) will randomly invite to participate mild obese or overweight patients of both gender, aged between 25 and 65 years old, who spend 6 hours at least daily sitting. A total of 232 subjects will be randomly allocated to an intervention (IG) and control group (CG) (116 individuals each group). In addition, 50 subjects with fibromyalgia will be included.Primary outcome is: (1) sitting time using the activPAL device and the Marshall questionnaire. The following parameters will be also assessed: (2) sitting time in work place (Occupational Sitting and Physical Activity Questionnaire), (3) health-related quality of life (EQ-5D), (4) evolution of stage of change (Prochaska and DiClemente's Stages of Change Model), (5) physical inactivity (catalan version of Brief Physical Activity Assessment Tool), (6) number of steps walked (pedometer and activPAL), (7) control based on analysis (triglycerides, total cholesterol, HDL, LDL, glycemia and, glycated haemoglobin in diabetic patients) and (8) blood pressure and anthropometric variables. All parameters will be assessed pre and post intervention and there will be a follow up three, six and twelve months after the intervention. A descriptive analysis of all variables and a multivariate analysis to assess differences among groups will be undertaken. Multivariate analysis will be carried out to assess time changes of dependent variables. All the analysis will be done under the intention to treat principle.

DISCUSSION

If the SEDESTACTIV intervention shows its effectiveness in reducing sitting time, health professionals would have a low-cost intervention tool for sedentary overweight and obese patients management.

TRIAL REGISTRATION

A service of the U.S. National Institutes of Health. Developed by the National Library of Medicine. ClinicalTrials.gov NCT01729936.

Developing a checklist for research proposals to help describe health service interventions in UK research programmes: a mixed methods study

Background

One of the most common reasons for rejecting research proposals in the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme is the failure to adequately specify the intervention or context in research proposals. Examples of failed research proposals include projects to assess integrated care models, use of generic caseworkers, or new specialist nurse services. These are all important service developments which need evaluation, but the lack of clarity about the intervention and context prevented these research proposals from obtaining funding. The purpose of the research presented herein was to develop a checklist, with key service intervention and contextual features, for use by applicants to the NIHR HS&DR Programme to potentially enhance the quality of research proposals.

Methods

The study used mixed methods to identify the need for and develop and test a checklist. Firstly, this included assessing existing checklists in peer-reviewed literature relevant to organisational health research. Building on existing work, a new checklist was piloted. Two reviewers used a small sample (n = 16) of research proposals to independently assess the relevance of the checklist to the proposal and the degree of overlap or gaps between the constructs. The next two stages externally validated the revised checklist by collecting qualitative feedback from researchers and experts in the field.

Results

The initial checklist was developed from existing checklists which included domains of intervention and context. The constructs and background to each were developed through review of existing literature. Eight researchers provided feedback on the checklist, which was generally positive. This iterative process resulted in changes to the checklist, collapsing two constructs and providing more prompts for others; the final checklist includes six constructs.

Conclusions

Features relating to intervention and context should be well described to increase the quality of research proposals and enhance the chances of the research receiving funding. Existing checklists do not have enough focus on areas relevant to research proposals in complex health service interventions, such as workforce. A formative checklist has been developed, and tested by end users. Tentative findings suggest usefulness and acceptability of such a tool but further work is needed for full validation.

Catgut implantation at acupoints for allergic rhinitis: a systematic review

OBJECTIVE

To assess the effectiveness and the possible adverse effects of catgut implantation at acupoints for allergic rhinitis (AR).

METHODS

This systematic review was carried out in accordance with the Cochrane Handbook version 5.1.0 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Extensive literature searches were conducted in PubMed, Excerpta Medical Databases, the Cochrane Library, the China National Infrastructure, Wanfang Chinese Digital Periodical and Conference Database, and the Weipu Chinese Science and Technique Journals Database. The Chinese Clinical Trial Registry Center was also searched for ongoing trials up to September 2012. Randomized controlled trials (RCTs) or quasi-RCTs were included. Risk of bias assessment was performed using the Cochrane tool for assessing risk of bias.

RESULTS

Five RCTs with 285 participants were found from 49 relevant studies, but there was just one RCT which met the inclusion criteria for this review. The study showed that treatment of catgut implantation at acupoints could lead to a better alleviation of the signs and symptoms of AR than the crude herb moxibustion. No adverse events were reported in this study.

CONCLUSIONS

Because of the methodological shortcoming and the risk of bias of the included trial, catgut implantation was proved with only limited evidence for the treatment of AR. Robust RCTs with high quality and larger sample size in this field are hoped to be carried out in the future.

Nigella sativa L. seeds modulate mood, anxiety and cognition in healthy adolescent males

ETHNOPHARMACOLOGICAL RELEVANCE

Previous studies conducted on animals linked consumption of Nigella sativa L. seeds (NS) to decreased anxiety and improved memory. The present study, which was carried out at a boarding school in Bangladesh, was designed to examine probable effect of NS on mood, anxiety and cognition in adolescent human males.

MATERIALS AND METHODS

Forty-eight healthy adolescent human males aged between 14 to 17 years were randomly recruited as volunteers and were randomly split into two groups: A (n=24) and B (n=24). The treatment procedure for group A and B were one capsule of 500 mg placebo and 500 mg NS respectively once daily for four weeks. All the volunteers were assessed for cognition with modified California verbal learning test-II (CVLT-II), mood with Bond-Lader scale and anxiety with State-Trait Anxiety Inventory (STAI) at the beginning and after four weeks of either NS or placebo ingestion.

RESULTS AND DISCUSSION

No parameter showed statistically significant variation between A and B in measurements in the beginning, but after 4 weeks of one capsule of NS 500 mg intake, there was statistically significant variation of mood within group B but there was not statistically significant variation between group A and B. No significant variation was found in state anxiety within groups and between group A and B but in case of trait anxiety, significant variation was found within group B but not between group A and B. In case of CVLT II, there was significant variation within B in immediate short-term recall at trial 4 and 5 whereas this difference was found only in case of trial 5 between group A and B. Within group B, short term-free recall, long-term free recall and long-term cued recall had statistical difference whereas between group A and B long-term free recall and long-term cued recall had statistical difference. No parameters had significant variation within group A after placebo intake for 4 weeks.

CONCLUSIONS

Over the 4 weeks study period, the use of NS as a nutritional supplement been observed to- stabilize mood, decrease anxiety and modulate cognition positively. However, long term study is suggested before using NS extensively.

The effect of rosuvastatin on inflammation, matrix turnover and left ventricular remodeling in dilated cardiomyopathy: a randomized, controlled trial

Background

Dilated cardiomyopathy is characterized by left ventricular dilatation and dysfunction. Inflammation and adverse remodeling of the extracellular matrix may be involved in the pathogenesis. Statins reduce levels of low density lipoprotein cholesterol, but may also attenuate inflammation and affect matrix remodeling. We hypothesized that treatment with rosuvastatin would reduce or even reverse left ventricular remodeling in dilated cardiomyopathy.

Materials and Methods

In this multicenter, randomized, double blind, placebo-controlled study, 71 patients were randomized to 10 mg of rosuvastatin or matching placebo. Physical examination, blood sampling, echocardiography and cardiac magnetic resonance imaging were performed at baseline and at six months’ follow-up. The pre-specified primary end point was the change in left ventricular ejection fraction from baseline to six months.

Results

Over all, left ventricular ejection fraction improved 5 percentage points over the duration of the study, but there was no difference in the change in left ventricular ejection fraction between patients allocated to rosuvastatin and those allocated to placebo. Whereas serum low density lipoprotein cholesterol concentration fell significantly in the treatment arm, rosuvastatin did not affect plasma or serum levels of a wide range of inflammatory variables, including C-reactive protein. The effect on markers of extracellular matrix remodeling was modest.

Conclusion

Treatment with rosuvastatin does not improve left ventricular ejection fraction in patients with dilated cardiomyopathy.

Trial Registration

ClinicalTrials.gov NCT00505154

Comparing DNA integration site clusters with scan statistics

MOTIVATION

Gene therapy with retroviral vectors can induce adverse effects when those vectors integrate in sensitive genomic regions. Retroviral vectors are preferred that target sensitive regions less frequently, motivating the search for localized clusters of integration sites and comparison of the clusters formed by integration of different vectors. Scan statistics allow the discovery of spatial differences in clustering and calculation of false discovery rates providing statistical methods for comparing retroviral vectors.

RESULTS

A scan statistic for comparing two vectors using multiple window widths is proposed with software to detect clustering differentials and compute false discovery rates. Application to several sets of experimentally determined HIV integration sites demonstrates the software. Simulated datasets of various sizes and signal strengths are used to determine the power to discover clusters and evaluate a convenient lower bound. This provides a toolkit for planning evaluations of new gene therapy vectors.

AVAILABILITY AND IMPLEMENTATION

The geneRxCluster R package containing a simple tutorial and usage hints is available from http://www.bioconductor.org.

Evaluation of the impact of a psycho-educational intervention on knowledge levels and psychological outcomes for people diagnosed with Schizophrenia and their caregivers in Jordan: a randomized controlled trial

BACKGROUND

Schizophrenia is one of the most serious forms of mental illness among people being treated in psychiatric clinics in developing and developed countries. Providing care for people diagnosed with schizophrenia can be stressful for their caregivers. Psycho-educational interventions may improve patients' and primary caregivers' knowledge of schizophrenia and impact positively on patients' physical and psychological outcomes and primary caregivers' burden of care and quality of life. Studies thus far have shown that these interventions may improve patients' and caregivers' outcomes, but the quality of included randomized controlled trials (RCTs) is poor and it is difficult to draw firm conclusions as to the effectiveness of such interventions on patients and primary caregivers' outcomes, hence the current study.

METHODS/DESIGN

A randomized controlled trial in four outpatient mental health clinics in Jordan comparing psycho-educational interventions in the form of six booklets every fortnight, with treatment as usual in people diagnosed with schizophrenia and their primary caregivers. The primary outcome for participants is knowledge of Schizophrenia; secondary outcomes for patients are positive and negative symptoms of schizophrenia and relapse rate, while secondary outcomes for primary caregivers are burden of care and quality of life. All measures are assessed at baseline, immediately post-intervention and at three months follow-up.

DISCUSSION

This randomized control trial, conducted in Jordan among people living with schizophrenia and their primary caregivers, will assess the effect of psycho-educational interventions on knowledge of Schizophrenia, patients' positive and negative symptoms and quality of life, and caregivers' burden of care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78084871.

Evaluation of Kilifi epilepsy education programme: a randomized controlled trial

Objectives

The epilepsy treatment gap is largest in resource-poor countries. We evaluated the efficacy of a 1-day health education program in a rural area of Kenya. The primary outcome was adherence to antiepileptic drugs (AEDs) as measured by drug levels in the blood, and the secondary outcomes were seizure frequency and Kilifi Epilepsy Beliefs and Attitudes Scores (KEBAS).

Methods

Seven hundred thirty-eight people with epilepsy (PWE) and their designated supporter were randomized to either the intervention (education) or nonintervention group. Data were collected at baseline and 1 year after the education intervention was administered to the intervention group. There were 581 PWE assessed at both time points. At the end of the study, 105 PWE from the intervention group and 86 from the nonintervention group gave blood samples, which were assayed for the most commonly used AEDs (phenobarbital, phenytoin, and carbamazepine). The proportions of PWE with detectable AED levels were determined using a standard blood assay method. The laboratory technicians conducting the assays were blinded to the randomization. Secondary outcomes were evaluated using questionnaires administered by trained field staff. Modified Poisson regression was used to investigate the factors associated with improved adherence (transition from nonoptimal AED level in blood at baseline to optimal levels at follow-up), reduced seizures, and improved KEBAS, which was done as a post hoc analysis. This trial is registered in ISRCTN register under ISRCTN35680481.

Results

There was no significant difference in adherence to AEDs based on detectable drug levels (odds ratio [OR] 1.46, 95% confidence interval [95% CI] 0.74–2.90, p = 0.28) or by self-reports (OR 1.00, 95% CI 0.71–1.40, p = 1.00) between the intervention and nonintervention group. The intervention group had significantly fewer beliefs about traditional causes of epilepsy, cultural treatment, and negative stereotypes than the nonintervention group. There was no difference in seizure frequency. A comparison of the baseline and follow-up data showed a significant increase in adherence—intervention group (36–81% [p < 0.001]) and nonintervention group (38–74% [p < 0.001])—using detectable blood levels. The number of patients with less frequent seizures (≤3 seizures in the last 3 months) increased in the intervention group (62–80% [p = 0.002]) and in the nonintervention group (67–75% [p = 0.04]). Improved therapeutic adherence (observed in both groups combined) was positively associated with positive change in beliefs about risks of epilepsy (relative risk [RR] 2.00, 95% CI 1.03–3.95) and having nontraditional religious beliefs (RR 2.01, 95% CI 1.01–3.99). Reduced seizure frequency was associated with improved adherence (RR 1.72, 95% CI 1.19–2.47). Positive changes in KEBAS were associated with having tertiary education as compared to none (RR 1.09, 95% CI 1.05–1.14).

Significance

Health education improves knowledge about epilepsy, but once only contact does not improve adherence. However, sustained education may improve adherence in future studies.

Physiotherapy Rehabilitation for Osteoporotic Vertebral Fracture (PROVE): study protocol for a randomised controlled trial

BACKGROUND

Osteoporosis and vertebral fracture can have a considerable impact on an individual's quality of life. There is increasing evidence that physiotherapy including manual techniques and exercise interventions may have an important treatment role. This pragmatic randomised controlled trial will investigate the clinical and cost-effectiveness of two different physiotherapy approaches for people with osteoporosis and vertebral fracture, in comparison to usual care.

METHODS/DESIGN

Six hundred people with osteoporosis and a clinically diagnosed vertebral fracture will be recruited and randomly allocated to one of three management strategies, usual care (control - A), an exercise-based physiotherapy intervention (B) or a manual therapy-based physiotherapy intervention (C). Those in the usual care arm will receive a single session of education and advice, those in the active treatment arms (B + C) will be offered seven individual physiotherapy sessions over 12 weeks. The trial is designed as a prospective, adaptive single-blinded randomised controlled trial. An interim analysis will be completed and if one intervention is clearly superior the trial will be adapted at this point to continue with just one intervention and the control. The primary outcomes are quality of life measured by the disease specific QUALLEFO 41 and the Timed Loaded Standing test measured at 1 year.

DISCUSSION

There are a variety of different physiotherapy packages used to treat patients with osteoporotic vertebral fracture. At present, the indication for each different therapy is not well defined, and the effectiveness of different modalities is unknown.

TRIAL REGISTRATION

Reference number ISRCTN49117867.

BMC Medicine: a decade of open access medical research

On 24 November 2003, BMC Medicine published its first article. Ten years and over 900 articles later we look back at some of the most notable milestones for the journal and discuss advances and innovations in medicine over the last decade. Our editorial board members, Leslie Biesecker, Thomas Powles, Chris Del Mar, Robert Snow and David Moher, also comment on the changes they expect to see in their fields over the coming years.

Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomised controlled trial

Background

Ankle sprain is the most common sports-related injury with a high rate of recurrence and associated costs. Recent studies have emphasised the effectiveness of both neuromuscular training and bracing for the secondary prevention of ankle sprains.

Aim

To evaluate the effectiveness of combined bracing and neuromuscular training, or bracing alone, against the use of neuromuscular training on recurrences of ankle sprain after usual care.

Methods

384 athletes, aged 18–70, who had sustained a lateral ankle sprain, were included (training group n=120; brace group n=126; combi group n=138). The training group received an 8-week home-based neuromuscular training programme, the brace group received a semirigid ankle brace to be worn during all sports activities for 12 months, and the combi group received both the training programme, as well as the ankle brace, to be worn during all sports activities for 8 weeks. The main outcome measure was self-reported recurrence of the ankle sprain.

Results

During the 1-year follow-up, 69 participants (20%) reported a recurrent ankle sprain: 29 (27%) in the training group, 17 (15%) in the brace group and 23 (19%) in the combi group. The relative risk for a recurrent ankle sprain in the brace group versus the training group was 0.53 (95% CI 0.29 to 0.97). No significant differences were found for time losses or costs due to ankle sprains between the intervention groups.

Conclusions

Bracing was superior to neuromuscular training in reducing the incidence but not the severity of self-reported recurrent ankle sprains after usual care.

Taming a wandering attention: short-form mindfulness training in student cohorts

Mindfulness training (MT) is a form of mental training in which individuals engage in exercises to cultivate an attentive, present centered, and non-reactive mental mode. The present study examines the putative benefits of MT in University students for whom mind wandering can interfere with learning and academic success. We tested the hypothesis that short-form MT (7 h over 7 weeks) contextualized for the challenges and concerns of University students may reduce mind wandering and improve working memory. Performance on the sustained attention to response task (SART) and two working memory tasks (operation span, delayed-recognition with distracters) was indexed in participants assigned to a waitlist control group or the MT course. Results demonstrated MT-related benefits in SART performance. Relative to the control group, MT participants had higher task accuracy and self-reported being more “on-task” after the 7-week training period. MT did not significantly benefit the operation span task or accuracy on the delayed-recognition task. Together these results suggest that while short-form MT did not bolster working memory task performance, it may help curb mind wandering and should, therefore, be further investigated for its use in academic contexts.

Motor impairment factors related to brain injury timing in early hemiparesis. Part I: expression of upper-extremity weakness

BACKGROUND

Extensive neuromotor development occurs early in human life, but the time that a brain injury occurs during development has not been rigorously studied when quantifying motor impairments.

OBJECTIVE

This study investigated the impact of timing of brain injury on the magnitude and distribution of weakness in the paretic arm of individuals with childhood-onset hemiparesis.

METHODS

A total of 24 individuals with hemiparesis were divided into time periods of injury before birth (PRE-natal, n = 8), around the time of birth (PERI-natal, n = 8), or after 6 months of age (POST-natal, n = 8). They, along with 8 typically developing peers, participated in maximal isometric shoulder, elbow, wrist, and finger torque generation tasks using a multiple-degree-of-freedom load cell to quantify torques in 10 directions. A mixed-model ANOVA was used to determine the effect of group and task on a calculated relative weakness ratio between arms.

RESULTS

There was a significant effect of both time of injury group (P < .001) and joint torque direction (P < .001) on the relative weakness of the paretic arm. Distal joints were more affected compared with proximal joints, especially in the POST-natal group.

CONCLUSIONS

The distribution of weakness provides evidence for the relative preservation of ipsilateral corticospinal motor pathways to the paretic limb in those individuals injured earlier, whereas those who sustained later injury may rely more on indirect ipsilateral corticobulbospinal projections during the generation of torques with the paretic arm.

Feasibility trial of a film-based educational intervention for increasing boys' and girls' intentions to avoid teenage pregnancy: Study protocol

The World Health Organisation, amongst others, recognises that adolescent men have a vital yet neglected role in reducing teenage pregnancies and that there is a pressing need for educational interventions designed especially for them. This study seeks to fill this gap by determining the feasibility of conducting an effectiveness trial of the If I Were Jack intervention in post-primary schools. This 4-week intervention aims to increase teenagers' intentions to avoid unintended pregnancy and addresses gender inequalities in sex education by explicitly focusing on young men. A cluster randomised feasibility trial with embedded process evaluation will determine: recruitment, participation and retention rates; quality of implementation; acceptability and feasibility of the intervention and trial procedures; and costs.

The Communication AssessmenT Checklist in Health (CATCH): a tool for assessing the quality of printed educational materials for clinicians

INTRODUCTION

There is little guidance available on strategies to improve the communication quality of printed educational materials (PEMs) for clinicians. The purposes of this study were to conceptualize PEM communication quality, develop a checklist based on this conceptualization, and validate the checklist with a selection of PEMs.

METHODS

From a literature review of the strategies influencing communication quality, we generated a conceptual map and developed the Communication AssessmenT Checklist in Health (CATCH) consisting of 55 items nested in 12 concepts. Two raters independently applied CATCH to 45 PEMs evaluated in the studies included in a Cochrane systematic review. From these results, we conducted an item analysis and assessed content validity of CATCH using a hierarchical cluster analysis to explore the extent to which our CATCH operationalization truly represented the communication quality concepts.

RESULTS

Some concepts were better covered in the studied PEMs, whereas others were not covered consistently. We observed 3 contrasting PEM clusters. A first cluster (n = 22) was characterized by longer PEMs and comprised mostly high-impact peer-reviewed scientific articles or clinical practice guidelines. A second cluster (n = 22) consisted of PEMs shorter than 4 pages that used special fonts, color, pictures, and graphics. A third cluster consisted of a single brief PEM.

DISCUSSION

With CATCH it is possible to categorize and understand the mechanisms that can trigger a change in behavior in health care providers. Additional research is needed to validate CATCH before it can be recommended for use.

Short- and long-term effects of tactile massage on salivary cortisol concentrations in Parkinson's disease: a randomised controlled pilot study

BACKGROUND

Parkinson's disease (PD) is a chronic neurodegenerative disorder with limited knowledge about the normal function and effects of non-pharmacological therapies on the hypothalamic-pituitary-adrenal (HPA) axis. The aim of the study was to analyse the basal diurnal and total secretion of salivary cortisol in short- and long-term aspects of tactile massage (TM).

METHODS

DESIGN

Prospective, Controlled and Randomised Multicentre Trial.

SETTING AND INTERVENTIONS

Forty-five women and men, aged 50-79 years, were recruited. Twenty-nine of them were blindly randomised to tactile massage (TM) and 16 of them to the control group, rest to music (RTM). Ten interventions were given during 8 weeks followed by a 26 weeks of follow up. Salivary cortisol was collected at 8 am, 1 pm, 8 pm, and 8 am the next day, on five occasions. With the first and eighth interventions, it was collected immediately before and after intervention.

MAIN OUTCOME MEASURES

The primary aim was to assess and compare cortisol concentrations before and immediately after intervention and also during the follow-up period. The secondary aim was to assess the impact of age, gender, body mass index (BMI), duration and severity of PD, effects of interventional time-point of the day, and levodopa doses on cortisol concentration.

RESULTS

The median cortisol concentrations for all participants were 16.0, 5.8, 2.8, and 14.0 nmol/L at baseline, later reproduced four times without significant differences. Cortisol concentrations decreased significantly after TM intervention but no change in diurnal salivary cortisol pattern was found. The findings of reduced salivary cortisol concentrations immediately after the interventions are in agreement with previous studies. However, there was no significant difference between the TM and control groups. There were no significant correlations between cortisol concentrations and age, gender, BMI, time-point for intervention, time interval between anti-parkinson pharmacy intake and sampling, levodopa doses, duration, or severity of PD.

CONCLUSIONS

Diurnal salivary cortisol rhythm was normal. Salivary cortisol concentrations were significantly reduced after the TM intervention and after RTM, but there were no significant differences between the groups and no sustained long-term effect. No associations were seen between salivary cortisol concentration and clinical and/or pharmacological characteristics.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT01734876 and FoU Sweden 108881.

Cellulite and focused extracorporeal shockwave therapy for non-invasive body contouring: a randomized trial

INTRODUCTION

Focused extracorporeal shockwave therapy (ESWT) has been demonstrated to improve wound healing and skin regeneration such as in burn wounds and scars. We hypothesized that the combination of focused ESWT and a daily gluteal muscle strength program is superior to SHAM-ESWT and gluteal muscle strength training in moderate to severe cellulite.

METHODS

This was a single-center, double-blinded, randomized-controlled trial. For allocation of participants, a 1:1 ratio randomization was performed using opaque envelopes for the concealment of allocation. Eligible patients were females aged 18-65 years with cellulite. The primary outcome parameter was the photo-numeric Cellulite Severity Scale (CSS) determined by two blinded, independent assessors. The intervention group (group A) received six sessions of focused ESWT (2,000 impulses, 0.35 mJ/mm(2), every 1-2 weeks) at both gluteal and thigh regions plus specific gluteal strength exercise training. The control group (group B) received six sessions of SHAM-ESWT plus specific gluteal strength exercise training.

RESULTS

The CSS in group A was 10.9 ± 3.8 (mean ± SE) before intervention and 8.3 ± 4.1 after 12 weeks (P = 0.001, 2.53 improvement, 95% confidence interval (CI) 1.43-3.62). The CSS in group B was 10.0 ± 3.8 before intervention and 10.1 ± 3.8 after 12 weeks (P = 0.876, 95% CI 1.1-0.97). The change of the CSS in group A versus group B was significantly different (P = 0.001, -24.3 effect size, 95% CI -36.5 to -12.1).

CONCLUSION

The combination of non-invasive, focused ESWT (0.35 mJ/mm(2), 2,000 impulses, 6 sessions) in combination with gluteal strength training was superior to gluteal strength training and SHAM-ESWT in moderate to severe cellulite in terms of the CSS in a 3-month perspective. Long-term results have to be evaluated in terms of the sustainability of these effects.

Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial

Objective

The purpose of this study was to investigate if the levonorgestrel-impregnated intrauterine device (LNG-IUS, Mirena®) is safe and effective as therapy for low-risk and medium-risk endometrial hyperplasia compared with oral medroxyprogesterone (MPA).

Design

A multicentre randomised trial.

Setting

Norway.

Population

In all, 170 women aged 30–70 years with low- or medium-risk endometrial hyperplasia who met inclusion criteria.

Methods

Patients were randomly assigned to one of three treatment arms: LNG-IUS; oral MPA 10 mg administered for 10 days per cycle, or continuous oral MPA 10 mg daily, for 6 months.

Main outcome measures

The primary outcome measure was normalisation or persisting hyperplasia.

Results

After 6 months all three treatment regimens showed significant effect when the outcome was evaluated as therapy response or not (P < 0.001). Responses were obtained for all the women in the LNG-IUS group (53/53, 95% CI 0.93–1.0) and for 96% of the women in the continuous oral group (46/48, 95% CI 0.86–0.99). Only 69% of the women in the cyclic oral group were responders (36/52, 95% CI 0.55–0.81). Adverse effects were relatively common with minimal differences between therapy groups.

Conclusion

In the first trial of its kind, women treated with the LNG-IUS showed histologically normal endometrium after 6 months of therapy for endometrial hyperplasia. Cyclical progestogens are found to be less effective compared with continuous oral therapy and LNG-IUS and should not be used for this purpose.

Randomised controlled trial of a tailored information pack for patients undergoing surgery and treatment for rectal cancer

PURPOSE

To evaluate the effects of a tailored information package for rectal cancer patients on satisfaction with information, anxiety and depression and readjustment.

METHOD

The study used a randomised control trial method. Seventy six patients undergoing surgery and treatment for rectal cancer were randomly assigned to an intervention (n = 43) or control group (n = 33). The intervention group received an information pack tailored according to their treatment plan and preferred information. The control group received the information currently given to these patients. Satisfaction with information was measured using the Patient Satisfaction with Cancer Treatment Education (PSCaTE) scale, anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) and readjustment was measured using the Reintegration to Normal Living Index, at three time points.

RESULTS

There was a statistically significant difference between the intervention and control group on pre and post intervention scores with patients in the intervention group expressing a higher level of satisfaction with information than those in the control group at Times 2 and 3 (p = 0.00 for both). The intervention group also had a significantly lower anxiety score than the control group at Time 3 (p = 0.03). There was no difference between depression and readjustment scores in the two groups.

CONCLUSION

The results support the hypothesis that a tailored information pack for patients with rectal cancer will positively affect satisfaction with information. These results will enhance the knowledge base surrounding the provision of tailored information to specific patient groups.

Chinese herbal medicine for postinfectious cough: a systematic review of randomized controlled trials

Chinese herbal medicine has been commonly used in the treatment of postinfectious cough. The aim of this review is to systematically evaluate the efficacy and safety of Chinese herbal medicine for postinfectious cough. An extensive search for RCTs was performed using multiple electronic databases, supplemented with a manual search. All studies included were confirmed with specific inclusion criteria. Methodological quality of each study was examined according to the Cochrane risk of bias assessment. Quality of evidence was evaluated using rating approach developed by GRADE working group. The literature search yielded 352 results, of which 12 RCTs satisfied the inclusion criteria, offering moderate-to-high levels of evidence. Methodological quality was considered high in three trials, while in the other nine studies the unclear risk of bias was in the majority. Findings suggested that, compared with western conventional medicine or placebo, Chinese herbal medicine could effectively improve core symptoms of postinfectious cough, act better and have earlier antitussive effect, and enhance patients' quality of life. No serious adverse event was reported.

A look at the potential association between PICOT framing of a research question and the quality of reporting of analgesia RCTs

BACKGROUND

Methodologists have proposed the formation of a good research question to initiate the process of developing a research protocol that will guide the design, conduct and analysis of randomized controlled trials (RCTs), and help improve the quality of reporting such studies. Five constituents of a good research question based on the PICOT framing include: Population, Intervention, Comparator, Outcome, and Time-frame of outcome assessment. The aim of this study was to analyze if the presence a structured research question, in PICOT format, in RCTs used within a 2010 meta-analysis investigating the effectiveness of femoral nerve blocks after total knee arthroplasty, is independently associated with improved quality of reporting.

METHODS

Twenty-three RCT reports were assessed for the quality of reporting and then examined for the presence of the five constituents of a structured research question based on PICOT framing. We created a PICOT score (predictor variable), with a possible score between 0 and 5; one point for every constituent that was included. Our outcome variable was a 14 point overall reporting quality score (OQRS) and a 3 point key methodological items score (KMIS) based on the proper reporting of allocation concealment, blinding and numbers analysed using the intention-to-treat principle. Both scores, OQRS and KMIS, are based on the Consolidated Standards for Reporting Trials (CONSORT) statement. A multivariable regression analysis was conducted to determine if PICOT score was independently associated with OQRS and KMIS.

RESULTS

A completely structured PICOT score question was found in 2 of the 23 RCTs evaluated. Although not statistically significant, higher PICOT was associated with higher OQRS [IRR: 1.267; 95% confidence interval (CI): 0.984, 1.630; p = 0.066] but not KMIS (1.061 (0.515, 2.188); 0.872). These results are comparable to those from a similar study in terms of the direction and range of IRRs estimates. The results need to be interpreted cautiously due to the small sample size.

CONCLUSIONS

This study showed that PICOT framing of a research question in anesthesia-related RCTs is not often followed. Even though a statistically significant association with higher OQRS was not found, PICOT framing of a research question is still an important attribute within all RCTs.

Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial

BACKGROUND

Mobile phone-based psychological interventions enable real time self-monitoring and self-management, and large-scale dissemination. However, few studies have focussed on mild-to-moderate symptoms where public health need is greatest, and none have targeted work and social functioning. This study reports outcomes of a CONSORT-compliant randomised controlled trial (RCT) to evaluate the efficacy of myCompass, a self-guided psychological treatment delivered via mobile phone and computer, designed to reduce mild-to-moderate depression, anxiety and stress, and improve work and social functioning.

METHOD

Community-based volunteers with mild-to-moderate depression, anxiety and/or stress (N = 720) were randomly assigned to the myCompass program, an attention control intervention, or to a waitlist condition for seven weeks. The interventions were fully automated, without any human input or guidance. Participants' symptoms and functioning were assessed at baseline, post-intervention and 3-month follow-up, using the Depression, Anxiety and Stress Scale and the Work and Social Adjustment Scale.

RESULTS

Retention rates at post-intervention and follow-up for the study sample were 72.1% (n = 449) and 48.6% (n = 350) respectively. The myCompass group showed significantly greater improvement in symptoms of depression, anxiety and stress and in work and social functioning relative to both control conditions at the end of the 7-week intervention phase (between-group effect sizes ranged from d = .22 to d = .55 based on the observed means). Symptom scores remained at near normal levels at 3-month follow-up. Participants in the attention control condition showed gradual symptom improvement during the post-intervention phase and their scores did not differ from the myCompass group at 3-month follow-up.

CONCLUSIONS

The myCompass program is an effective public health program, facilitating rapid improvements in symptoms and in work and social functioning for individuals with mild-to-moderate mental health problems.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN 12610000625077.

Twelve-months follow-up of supervised exercise after percutaneous transluminal angioplasty for intermittent claudication: a randomised clinical trial

The aim of this study was to explore the effects during 12 months follow-up of 12 weeks of supervised exercise therapy (SET) after percutaneous transluminal angioplasty (PTA) compared to PTA alone on physical function, limb hemodynamics and health-related quality of life (HRQoL) in patients with intermittent claudication. Fifty patients were randomised to an intervention or a control group. Both groups received usual post-operative care and follow-up measurements at three, six and 12 months after PTA. The intervention group performed 12 weeks of SET after PTA. The control group did not receive any additional follow-up regarding exercise. During the 12 months' follow-up, the members of the intervention group had significantly better walking distance than the control group. The intervention group had a significantly higher HRQoL score in the physical component score of the SF-36, and the domains of physical function, bodily pain and vitality. For limb hemodynamics, there was a non-significant trend towards better results in the intervention group compared to the control group.

CONCLUSION

SET after PTA yielded statistically significantly better results for walking distance and HRQoL in the intervention group than the control group during the 12 months of follow-up.

A lifestyle intervention supported by mobile health technologies to improve the cardiometabolic risk profile of individuals at risk for cardiovascular disease and type 2 diabetes: study rationale and protocol

BACKGROUND

Metabolic syndrome is a cluster of cardiovascular risk factors that greatly increase the risk of developing cardiovascular disease and type 2 diabetes. Regular exercise improves the risk profile, but most people do not successfully change their exercise habits to beneficially reduce risk. Tailored exercise prescribed by a family physician has shown promise as a means to increase fitness and reduce cardiometabolic risk, but optimal implementation practices remain unknown. Mobile health technologies have proved to be a beneficial tool to achieve blood pressure and blood glucose control in patients with diabetes. These technologies may address the limited access to health interventions in rural and remote regions. However, the potential as a tool to support exercise-based prevention activities is not well understood. This study was undertaken to investigate the effects of a tailored exercise prescription alone or supported by mobile health technologies to improve metabolic syndrome and related cardiometabolic risk factors in rural community-dwelling adults at risk for cardiovascular disease and type 2 diabetes.

METHODS/DESIGN

Adults (n = 149) with at least two metabolic syndrome risk factors were recruited from rural communities and randomized to either: 1) an intervention group receiving an exercise prescription and devices for monitoring of risk factors with a smartphone data portal equipped with a mobile health application; or 2) an active control group receiving only an exercise prescription. All participants reported to the research centre at baseline, and at 12-, 24- and 52-week follow-up visits for measurement of anthropometrics and blood pressure and for a blood draw to test blood-borne markers of cardiometabolic health. Vascular and autonomic function were examined. Fitness was assessed and exercise prescribed according to the Step Test and Exercise Prescription protocol.

DISCUSSION

This study tested the effects of a prescriptive exercise intervention alone, versus one supported by mobile health technology on cardiometabolic risk factors. The intervention was designed to be translated into clinical or community-based programming. Results will contribute to the current literature by investigating the utility of mobile health technology support for exercise prescription interventions to improve cardiometabolic risk status and maintain improvements over time; particularly in rural communities.

TRIAL REGISTRATION

CLINICAL TRIALS REGISTRATION

NCT01944124.

Reduction of atherogenic risk in patients with type 2 diabetes by curcuminoid extract: a randomized controlled trial

Curcumin is a phytocompound found in the root of turmeric, a common herbal ingredient in many Asian cuisines. The compound contains anti-inflammatory activity, which is mediated through an up-regulation of adiponectin and reduction of leptin. Consumption of curcumin was shown to prevent some deteriorative conditions caused by inflammation, such as ulcerative colitis, rheumatoid arthritis and esophagitis, and so on. Inflammation-associated cardiovascular conditions such as atherosclerosis are common in diabetes patients. The anti-inflammation effect of curcumin might be beneficial to prevent such condition in these patients. We aim to evaluate an antiatherosclerosis effect of curcumin in diabetes patients. Effects of curcumin on risk factors for atherosclerosis were investigated in a 6-month randomized, double-blinded and placebo-controlled clinical trial that included subjects diagnosed with type 2 diabetes. An atherosclerosis parameter, the pulse wave velocity, and other metabolic parameters in patients treated with placebo and curcumin were compared. Our results showed that curcumin intervention significantly reduced pulse wave velocity, increased level of serum adiponectin and decreased level of leptin. These results are associated with reduced levels of homeostasis model assessment-insulin resistance, triglyceride, uric acid, visceral fat and total body fat. In summary, a 6-month curcumin intervention in type 2 diabetic population lowered the atherogenic risks. In addition, the extract helped to improve relevant metabolic profiles in this high-risk population.

Quality of reporting clinical trials published in five leading Sri Lankan medical journals

OBJECTIVES

To assess the quality of reporting of clinical trials published in five leading Sri Lankan medical journals.

METHODS

Six medical journals were hand searched for clinical trials published from 1982 to 2011. Eligible criteria were all randomized and non-randomized clinical trials conducted in humans. A checklist was developed based on CONSORT and TREND recommendations. Each study was independently evaluated by two reviewers. Outcome measures were presence of checklist items in published reports.

RESULTS

Fifteen randomized and 24 non-randomized parallel group trials from 724 studies in five journals met the inclusion criteria. Out of 39 trials, 39 (97%) clearly described the objectives, 16 (41%) defined the periods of recruitment, 7 (18%) reported how sample size was determined, 10 (25.6%) reported the methods to enhance the quality of measurements, 20 (51%) reported baseline demographic and clinical characteristics of each group, 4 (10%) showed flow diagrams, 23 (69%) reported statistical methods used to compare groups for primary outcomes, 21 (54%) reported effect size, 4 (10%) reported its precision, and 20 (51%) interpreted the results in the context of current evidence, and 5 (13%) described the generalizability of the findings. Of the 15 randomized trials, only one (7%) reported sequence generation, 5 (33%) allocation concealment, 9 (60%) reported blinding status of participants or investigators, and 2 (13%) reported intention to treat analysis.

CONCLUSIONS

Reporting of several essential recommendations remained suboptimal. Education and training of trial methods and awareness of the CONSORT and TREND statements and more attention to the quality of reporting may improve matters.

Clinical and radiographic outcomes of the use of four dressing materials in pulpotomized primary molars: a randomized clinical trial with 2-year follow-up

BACKGROUND

Although multiple materials have been suggested for pulpotomized primary molars, there is no reliable evidence of the superiority of one particular type.

AIM

To compare the effectiveness of formocresol (FC), mineral trioxide aggregate (MTA), ferric sulphate, and sodium hypochlorite (NaOCl) as pulp dressing agents in primary molars after 2 years.

DESIGN

One hundred primary molars requiring pulp treatment were allocated randomly to the control (FC) and experimental groups (MTA, ferric sulphate, and NaOCl). Clinical and radiographic evaluations were performed at 6, 12, 18, and 24 months. Statistical analysis using Fischer's exact test was performed to determine the significant differences between groups.

RESULTS

In the FC and MTA groups, 100% of the available teeth were clinically successful at all follow-up appointments. In the NaOCl group, one clinical failure was found at 18 months, and two clinical failures in the ferric sulphate group were noted at 12 and 24 months, but no significant differences were found among the groups (P = 0.41). No significant differences in radiographic success were found among all the groups at 24 months of follow-up (P = 0.303).

CONCLUSIONS

No statistically significant differences among the four materials were found at 24 months suggesting that NaOCl may be an appropriate substitute for FC.

Does goal setting in activity-focused interventions for children with cerebral palsy influence treatment outcome?

Today, treatment for children with cerebral palsy predominantly aims at improving the children's possibilities to perform everyday activities in their natural environment. The activities in focus for intervention are often expressed as specific goals, frequently defined in a collaborative goal-setting process between professionals and parents. The role of goal setting to improve the outcome of the intervention has not been shown in the literature so far. Thus, the aim of this systematic review was to explore if goal setting has an impact on treatment outcome assessed by standardized measures. CINAHL and MEDLINE were searched from January 2000 to October 2012, resulting in a final selection of 13 articles, six of which were randomized controlled trials. Methodological quality was assessed and study characteristics were analysed descriptively. Subject characteristics, type of intervention/s, frequency, and intensity of therapy varied largely. Outcome was assessed by standardized outcome measures as well as evaluated through aspects of goal attainment. Most studies showed robust within-group changes according to study-appropriate standardized measures, whereas the between-group comparisons exhibited less consistent differences in outcome. The review does not provide support for a positive effect of goal setting per se on treatment outcome. Studies that specifically measure the effect of goal setting on treatment outcome are needed.

Do pilocarpine drops help dry mouth in palliative care patients: a protocol for an aggregated series of n-of-1 trials

Background

It is estimated that 39,000 Australians die from malignant disease yearly. Of these, 60% to 88% of advanced cancer patients suffer xerostomia, the subjective feeling of mouth dryness. Xerostomia has significant physical, social and psychological consequences which compromise function and quality of life. Pilocarpine is one treatment for xerostomia. Most studies have shown some variation in individual response to pilocarpine, in terms of dose used, and timing and extent of response.

We will determine a population estimate of the efficacy of pilocarpine drops (6 mg) three times daily compared to placebo in relieving dry mouth in palliative care (PC) patients. A secondary aim is to assess individual patients’ response to pilocarpine and provide reports detailing individual response to patients and their treating clinician.

Methods/Design

Aggregated n-of-1 trials (3 cycle, double blind, placebo-controlled crossover trials using standardized measures of effect). Individual trials will identify which patients respond to the medication. To produce a population estimate of a treatment effect, the results of all cycles will be aggregated.

Discussion

Managing dry mouth with treatment supported by the best possible evidence will improve functional status of patients, and improve quality of life for patients and carers. Using n-of-1 trials will accelerate the rate of accumulation of high-grade evidence to support clinical therapies used in PC.

Trial registration

Australia and New Zealand Clinical Trial Registry Number: 12610000840088.

The 40-Something randomized controlled trial to prevent weight gain in mid-age women

Background

Obesity prevention is a major public health priority. Despite the health risks associated with weight gain, there has been a distinct lack of research into effective interventions to prevent, rather than treat, obesity particularly at high risk life stages such as menopause in women. This paper describes the rationale for and design of a 2-year randomized controlled trial (RCT) (the 40-Something Study) aimed at testing the feasibility and efficacy of a relatively low intensity intervention designed to achieve weight control in non-obese women about to enter the menopause transition.

Methods and design

The study is a parallel-group RCT consisting of 12 months of intervention (Phase 1) and 12 months of monitoring (Phase 2). Non-obese pre-menopausal healthy females 44–50 years of age were screened, stratified according to Body Mass Index (BMI) category (18.5-24.9 and 25–29.9 kg/m²) and randomly assigned to one of two groups: motivational interviewing (MI) intervention (n = 28), or a self-directed intervention (SDI) (control) (n = 26). The MI intervention consisted of five consultations with health professionals (four with a Dietitian and one with an Exercise Physiologist) who applied components of MI counselling to consultations with the women over a 12 month period. The SDI was developed as a control and these participants received print materials only. Outcome measures were collected at baseline, three, 12, 18 and 24 months and included weight (primary outcome), waist circumference, body composition, blood pressure, plasma markers of metabolic syndrome risk, dietary intake, physical activity and quality of life. Analysis of covariance will be used to investigate outcomes according to intervention type and duration (comparing baseline, 12 and 24 months).

Discussion

The 40-Something study is the first RCT aimed at preventing menopausal weight gain in Australian women. Importantly, this paper describes the methods used to evaluate whether a relatively low intensity, health professional led intervention will achieve better weight control in pre-menopausal women than a self-directed intervention. The results will add to the scant body of literature on obesity prevention methods at an under-researched high-risk life stage, and inform the development of population-based interventions.

Trial registration

ACTRN12611000064909

Evaluation of a family intervention programme for the treatment of overweight and obese children (Nereu Programme): a randomized clinical trial study protocol

BACKGROUND

Obesity is mainly attributed to environmental factors. In developed countries, the time spent on physical activity tasks is decreasing, whereas sedentary behaviour patterns are increasing.The purpose of the intervention is to evaluate the effectiveness of an intensive family-based behavioural multi-component intervention (Nereu programme) and compared it to counselling intervention such as a health centre intervention programme for the management of children's obesity.

METHODS/DESIGN

The study design is a randomized controlled multicenter clinical trial using two types of interventions: Nereu and Counselling. The Nereu programme is an 8-month intensive family-based multi-component behavioural intervention. This programme is based on a multidisciplinary intervention consisting of 4 components: physical activity sessions for children, family theoretical and practical sessions for parents, behaviour strategy sessions involving both, parents and children, and lastly, weekend extra activities for all. Counselling is offered to the family in the form of a monthly physical health and eating habits session. Participants will be recruited according the following criteria: 6 to 12 year-old-children, referred from their paediatricians due to overweight or obesity according the International Obesity Task Force criteria and with a sedentary profile (less than 2 hours per week of physical activity), they must live in or near the municipality of Lleida (Spain) and their healthcare paediatric unit must have previously accepted to cooperate with this study. The following variables will be evaluated: a) cardiovascular risk factors (anthropometric parameters, blood test and blood pressure), b) sedentary and physical activity behaviour and dietary intake, c) psychological aspects d) health related quality of life (HRQOL), e) cost-effectiveness of the intervention in relation to HRQOL. These variables will be then be evaluated 4 times longitudinally: at baseline, at the end of the intervention (8 months later), 6 and 12 months after the intervention. We have considered necessary to recruit 100 children and divide them in 2 groups of 50 to detect the differences between the groups.

DISCUSSION

This trial will provide new evidence for the long-term effects of childhood obesity management, as well as help to know the impact of the present intervention as a health intervention tool for healthcare centres.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01878994.

An evidence-based analysis of house dust mite allergen immunotherapy: a call for more rigorous clinical studies

BACKGROUND

According to meta-analyses and reviews, subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT) are beneficial in patients with allergic rhinitis (AR) and allergic asthma (AA) induced by house dust mites (HDMs). However, the reported effect sizes have varied greatly from one study to another.

OBJECTIVE

We sought to perform an evidence-based medicine assessment of commercially available SCIT and SLIT formulations in patients with HDM-induced AA and HDM-induced AR.

METHODS

We searched for double-blind, placebo-controlled randomized clinical trials and analyzed study designs, doses, regimens, patient-reported outcomes, safety reporting, and compliance.

RESULTS

Forty-four studies met our inclusion criteria. Some studies tested both SLIT and SCIT or scored both AA and AR outcomes; therefore we reviewed 35 treatment arms in patients with AA (20 for SCIT and 15 for SLIT) and 23 treatment arms in patients with AR (7 for SCIT and 16 for SLIT). The treatment duration ranged from 6 weeks to 3 years. For SCIT, the dose of Der p 1 major allergen (when reported) ranged from 7 to 30 μg for maintenance doses and 60 to 420 μg for cumulative doses. For SLIT, the doses of Der p 1 (when reported) were 0.8 to 70 μg for maintenance doses and 60 to 23,695 μg for cumulative doses. Safety data were often absent or poorly reported. A statistically significant active versus placebo symptom score was observed more frequently for SCIT than for SLIT.

CONCLUSION

There is no consensus on basic treatment parameters (eg, dose and duration) in HDM SCIT and SLIT. There is an urgent need for rigorous, long-term, double-blind, placebo-controlled randomized clinical trials with an efficacy criterion that reflects the particular features of HDM-induced allergic disease.

Internet-based, culturally sensitive, problem-solving therapy for Turkish migrants with depression: randomized controlled trial

BACKGROUND

Turkish migrants living in the Netherlands have a high prevalence of depressive disorders, but experience considerable obstacles to accessing professional help. Providing easily accessible Internet treatments may help to overcome these barriers.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a culturally sensitive, guided, self-help, problem-solving intervention through the Internet for reducing depressive symptoms in Turkish migrants.

METHODS

A two-armed randomized controlled trial was conducted. The primary outcome measure was the severity of depressive symptoms; secondary outcome measures were somatic symptoms, anxiety, quality of life, and satisfaction with the treatment. Participants were assessed online at baseline, posttest (6 weeks after baseline), and 4 months after baseline. Posttest results were analyzed on the intention-to-treat sample. Missing values were estimated by means of multiple imputation. Differences in clinical outcome between groups were analyzed with a t test. Cohen's d was used to determine the between-groups effect size at posttreatment and follow-up.

RESULTS

Turkish adults (N=96) with depressive symptoms were randomized to the experimental group (n=49) or to a waitlist control group (n=47). High attrition rates were found among the 96 participants of which 42% (40/96) did not complete the posttest (6 weeks) and 62% (59/96) participants did not complete the follow-up assessment at 4 months. No significant difference between the experimental group and the control group was found for depression at posttest. Recovery occurred significantly more often in the experimental group (33%, 16/49) than in the control group (9%, 4/47) at posttest (P=.02). Because of the high attrition rate, a completers-only analysis was conducted at follow-up. The experimental group showed significant improvement in depression compared to the control group both at posttest (P=.01) and follow-up (P=.01).

CONCLUSIONS

The results of this study did not show a significant effect on the reduction of depressive symptoms. However, the effect size at posttest was high, which might be an indicator of the possible effectiveness of the intervention when assessed in a larger sample and robust trial. Future research should replicate our study with adequately powered samples.

TRIAL REGISTRATION

Dutch Trial Register: NTR2303. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2303 (Archived by WebCite at http://www.webcitation.org/6IOxNgoDu).

Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (Transition Trial)

BACKGROUND

Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care. Suboptimal transition has been associated with higher risks for acute and chronic diabetes-related complications. The period of emerging adulthood challenges current systems of healthcare delivery as many young adults with type 1 diabetes (T1D) default from diabetes care and are at risk for diabetes complications which are undetected and therefore untreated. Despite the importance of minimizing loss to follow-up there are no randomized control trials evaluating models of transition from pediatric to adult diabetes care.

METHODS/DESIGN

This is a multicentre randomized controlled trial. A minimum of 188 subjects with T1D aged between 17 and 20 years will be evaluated. Eligible subjects will be recruited from three pediatric care centres and randomly assigned in a 1:1 ratio to a structured transition program that will span 18 months or to receive standard diabetes care. The structured transition program is a multidisciplinary, complex intervention aiming to provide additional support in the transition period. A Transition Coordinator will provide transition support and will provide the link between pediatric and adult diabetes care. The Transition Coordinator is central to the intervention to facilitate ongoing contact with the medical system as well as education and clinical support where appropriate. Subjects will be seen in the pediatric care setting for 6 months and will then be transferred to the adult care setting where they will be seen for one year. There will then be a one-year follow-up period for outcome assessment. The primary outcome is the proportion of subjects who fail to attend at least one outpatient adult diabetes specialist visit during the second year after transition to adult diabetes care. Secondary outcome measures include A1C frequency measurement and levels, diabetes related emergency room visits and hospital admissions, frequency of complication screening, and subject perception and satisfaction with care.

DISCUSSION

This trial will determine if the support of a Transition Coordinator improves health outcomes for this at-risk population of young adults.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT01351857.

Outcome measures and their measurement properties for trapeziometacarpal osteoarthritis: a systematic literature review

The objective was to identify all outcome measures used in studies on trapeziometacarpal osteoarthritis (TMC OA) and evaluate their measurement properties. In a two-step systematic literature review, we first identified studies including TMC OA patients and extracted all outcome measures. They were categorized according to the Outcome Measures in Rheumatology (OMERACT) core set for OA including five dimensions: pain, physical function, global assessment, imaging, and quality of life (QoL). Secondly, we retrieved articles on the measurement properties of the identified outcome measures for TMC OA patients. First, 316 articles including 101 different outcome measures were identified, addressing the OMERACT pain and function domains most frequently but under-representing QoL. Second, 12 articles investigating measurement properties of 12 outcome measures were identified. The methodological quality of these studies was poor to fair, implying that based on the literature no recommendations to use any of the outcome measures can yet be made.

Breathing exercises for adults with asthma

BACKGROUND

Breathing exercises have been widely used worldwide as a complementary therapy to the pharmacological treatment of people with asthma.

OBJECTIVES

To evaluate the evidence for the efficacy of breathing exercises in the management of patients with asthma.

SEARCH METHODS

The search for trials led review authors to review the literature available in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and AMED and to perform handsearching of respiratory journals and meeting abstracts. Trial registers and reference lists of included articles were also consulted.The literature search has been updated to January 2013.

SELECTION CRITERIA

We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. RevMan software was used for data analysis based on the fixed-effect model. Continuous outcomes were expressed as mean differences (MDs) with confidence intervals (CIs) of 95%. Heterogeneity was assessed by inspecting the forest plots. The Chi(2) test was applied, with a P value of 0.10 indicating statistical significance. The I(2) statistic was implemented, with a value greater than 50% representing a substantial level of heterogeneity.

MAIN RESULTS

A total of 13 studies involving 906 participants are included in the review. The trials were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number and duration of sessions completed, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. The following outcomes were measured: quality of life, asthma symptoms, number of acute exacerbations and lung function. Eleven studies compared breathing exercise with inactive control, and two with asthma education control groups. All eight studies that assessed quality of life reported an improvement in this outcome. An improvement in the number of acute exacerbations was observed by the only study that assessed this outcome. Six of seven included studies showed significant differences favouring breathing exercises for asthma symptoms. Effects on lung function were more variable, with no difference reported in five of the eleven studies that assessed this outcome, while the other six showed a significant difference for this outcome, which favoured breathing exercises. As a result of substantial heterogeneity among the studies, meta-analysis was possible only for asthma symptoms and changes in the Asthma Quality of Life Questionnaire (AQLQ). Each meta-analysis included only two studies and showed a significant difference favouring breathing exercises (MD -3.22, 95% CI -6.31 to -0.13 for asthma symptoms; MD 0.79, 95% CI 0.50 to 1.08 for change in AQLQ). Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included trials.

AUTHORS' CONCLUSIONS

Even though individual trials reported positive effects of breathing exercises, no reliable conclusions could be drawn concerning the use of breathing exercises for asthma in clinical practice. This was a result of methodological differences among the included studies and poor reporting of methodological aspects in most of the included studies. However, trends for improvement are encouraging, and further studies including full descriptions of treatment methods and outcome measurements are required.

Evaluation of a Swedish version of the Strengthening Families Programme

BACKGROUND

Adolescents' alcohol consumption is a public health concern in Sweden as well as in many other countries. Underage drinking is associated with increased risks of alcohol-related injuries, risky sexual behaviours and dependence later in life. Different strategies have been used in the effort to prevent this behaviour, and to postpone the onset of alcohol. The Strengthening Families Programme 10-14 (SFP 10-14) from the USA has been highlighted as one of the more effective prevention programmes. The aim of the present article was to evaluate the effectiveness of a culturally adapted Swedish version of the SFP 10-14.

METHODS

This was a cluster randomized controlled trial including 587 sixth-grade students (age 12) and their parents in 19 elementary schools in Stockholm. Schools were randomly assigned to either control (9 schools, 216 students) or to the family skills training intervention (10 schools, 371 students). The SFP Swedish version consisted of two parts with seven and five sessions, respectively, held separately for youths and parents except two joint family sessions. Measures of students' self-reported episodes of drunkenness, smoking, illicit drug use and other norm-breaking behaviours were collected at baseline (March 2003) and at three subsequent yearly surveys. Data were analysed using multilevel models with an intention-to-treat approach.

RESULTS

No preventive effects were found for smoking, alcohol and illicit drug use and other norm-breaking behaviours, nor did moderators affect the outcome.

CONCLUSION

The Swedish version of the SFP 10-14 was not effective in preventing youths' substance use in a Swedish context.

Recruitment, retention, and blinding in clinical trials

The recruitment and retention of participants and the blinding of participants, health care providers, and data collectors present challenges for clinical trial investigators. This article reviews challenges and alternative strategies associated with these three important clinical trial activities. Common recruiting pitfalls, including low sample size, unfriendly study designs, suboptimal testing locations, and untimely recruitment are discussed together with strategies for overcoming these barriers. The use of active controls, technology-supported visit reminders, and up-front scheduling is recommended to prevent attrition and maximize retention of participants. Blinding is conceptualized as the process of concealing research design elements from key players in the research process. Strategies for blinding participants, health care providers, and data collectors are suggested.

A sensitivity analysis of the Children's Treatment Network trial: a randomized controlled trial of integrated services versus usual care for children with special health care needs

Background

The value of integrated care through comprehensive, coordinated, and family-centered services has been increasingly recognized for improving health outcomes of children with special health care needs (CSHCN). In a randomized controlled trial (RCT), the integrated care provided through the Children’s Treatment Network (CTN) was compared with usual care in improving the psychosocial health of target CSHCN. In this paper, we aimed to estimate the effect of CTN care by conducting multiple analyses to handle noncompliance in the trial.

Methods

The trial recruited target children in Simcoe County and York Region, ON, Canada. Children were randomized to receive CTN or usual care and were followed for 2 years. The CTN group received integrated services through multiple providers to address their specific needs while the usual care group continued to receive care directed by their parents. The outcome was change in psychosocial quality of life at 2 years. We conducted intention-to-treat, as-treated, per-protocol, and instrumental variable analyses to analyze the outcome.

Results

The trial randomized 445 children, with 229 in the intervention group and 216 in the control group. During follow-up, 52% of children in the intervention group did not receive complete CTN care for various reasons. At 2 years, we did not find a significant improvement in psychosocial quality of life among the children receiving CTN care compared with usual care (intention-to-treat mean difference 1.50, 95% confidence interval −1.49 to 4.50; P = 0.32). Other methods of analysis yielded similar results.

Conclusion

Although the effect of CTN care was not significant, there was evidence showing benefits of integrated care for CSHCN. More RCTs are needed to demonstrate the magnitude of such an effect. The CTN study highlights the key challenges in RCTs when assessing interventions involving integrated care, and informs further RCTs including similar evaluations.

Vacuum-assisted wound closure versus alginate for the treatment of deep perivascular wound infections in the groin after vascular surgery

BACKGROUND

Vacuum-assisted wound closure (VAC) therapy may heal wounds faster than conventional dressings after surgical debridement of perivascular groin infections after vascular surgery.

METHODS

Patients with deep infected wounds (Szilagyi grade III) were surgically revised and left open for secondary healing, then randomized to either VAC or alginate (Sorbalgon) therapy, between February 2007 and November 2011. To test the hypothesis, it was calculated that 42 patients needed to be included (90% power, 5% level of significance). It was decided to perform an interim analysis after inclusion of 20 patients.

RESULTS

Among 66 patients undergoing groin revision, 20 patients were included in this study. Patients were randomized to VAC (n = 10) or alginate (n = 10). The two groups were comparable in patient and wound characteristics. Time to full skin epithelialization was significantly shorter in the VAC group (median, 57 days) compared with the alginate group (median, 104 days; P = .026). The number of positive wound cultures of bacteria and C-reactive protein values decreased equally in both groups between surgical revision and day 21. One femur amputation was performed in each group as a consequence of the groin infection, one patient died during the in-hospital stay in the alginate group, and none died in the VAC group.

CONCLUSIONS

VAC achieves faster healing than alginate therapy after wound debridement for deep perivascular wound infections in the groin after vascular surgery. This finding does not allow further inclusion of patients from an ethical point of view, and this study was, therefore, stopped prematurely.

Chest physiotherapy for pneumonia in children

BACKGROUND

Pneumonia is an inflammatory lung disease and it is the greatest cause of deaths in children younger than five years of age worldwide. Chest physiotherapy is widely used in the treatment of pneumonia because it can help to eliminate inflammatory exudates and tracheobronchial secretions, remove airway obstructions, reduce airway resistance, enhance gas exchange and reduce the work of breathing. Thus, chest physiotherapy may contribute to patient recovery as an adjuvant treatment even though its indication remains controversial.

OBJECTIVES

To assess the effectiveness of chest physiotherapy in relation to time until clinical resolution in children (from birth up to 18 years old) of either gender with any type of pneumonia.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4; MEDLINE (1946 to May week 4, 2013); EMBASE (1974 to May 2013); CINAHL (1981 to May 2013); LILACS (1982 to May 2013); Web of Science (1950 to May 2013); and PEDro (1950 to May 2013).We consulted the ClinicalTrials.gov and the WHO ICTRP registers to identify planned, ongoing and unpublished trials. We consulted the reference lists of relevant articles found by the electronic searches for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared chest physiotherapy of any type with no chest physiotherapy in children with pneumonia.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies to be included in the review, assessed trial quality and extracted data.

MAIN RESULTS

Three RCTs involving 255 inpatient children are included in the review. They addressed conventional chest physiotherapy, positive expiratory pressure and continuous positive airway pressure. The following outcomes were measured: duration of hospital stay, time to clinical resolution (observing the following parameters: fever, chest indrawing, nasal flaring, tachypnoea and peripheral oxygen saturation levels), change in adventitious sounds, change in chest X-ray and duration of cough in days. Two of the included studies found a significant improvement in respiratory rate and oxygen saturation whereas the other included study failed to show that standardised respiratory physiotherapy and positive expiratory pressure decrease the time to clinical resolution and the duration of hospital stay. No adverse effects related to the interventions were described. Due to the different characteristics of the trials, such as the duration of treatment, levels of severity, types of pneumonia and the techniques used in children with pneumonia, as well as differences in their statistical presentation, we were not able to pool data. Two included studies had an overall low risk of bias whereas one included study had an overall unclear risk of bias.

AUTHORS' CONCLUSIONS

Our review does not provide conclusive evidence to justify the use of chest physiotherapy in children with pneumonia due to a lack of data. The number of included studies is small and they differed in their statistical presentation.