Attention control group activities and perceived benefit in a trial of a behavioral intervention for older adults

Society for Vascular Surgery Clinical Practice Guideline on the Management of Intermittent Claudication: Focused Update

Intermittent claudication (IC) is the most common symptom of peripheral artery disease (PAD), which is a growing public health burden in the United States and globally. Patients with IC present with a broad spectrum of risk factors, comorbid conditions, range of disability, and treatment goals. Informed shared decision-making hinges on a comprehensive evaluation of these factors, patient education, and knowledge of the latest available evidence. In 2015 the Society for Vascular Surgery published a clinical practice guideline on the management of asymptomatic PAD and IC. An expert writing group was commissioned to provide a focused update to this guideline on the management of IC. Based on the available evidence from published research conducted since the prior guideline, six specific key questions were formulated spanning the areas of antithrombotic management, exercise therapy, and revascularization for IC. A systematic review and evidence synthesis of each question was conducted by a dedicated methodology team. The GRADE approach was employed to describe the strength of each recommendation and level of certainty of evidence. The review identified major gaps in evidence particularly in the arena of comparative effectiveness for interventions (exercise, revascularization) across defined clinical subgroups and employing meaningful patient-centered outcomes. Twelve recommendations, among which are two best practice statements, are provided in this focused update. They address the use of dual pathway antithrombotic strategies, the role and type of exercise therapy, endovascular interventions for femoropopliteal and infrapopliteal disease, and the identification of specific risk factors that should be incorporated into shared decision making around revascularization. A comprehensive and individualized approach to the management of patients with IC, relying first on education, risk factor control, optimal medical therapy, and exercise, is emphasized. A rubric for decision making that includes a thorough assessment of risk, benefits, degree of impairment and treatment durability, is considered fundamental to a patient-centered approach in IC. Significant unmet research needs in this field are also enumerated.

Effectiveness of psychotherapy for Hwa-Byung: A systematic review of interventional studies

BACKGROUND

This systematic review aimed to review and synthesize the effects of different psychotherapies on Hwa-Byung (HB), a Korean culture-bound syndrome.

METHODS

Ten electronic databases were comprehensively searched for interventional studies on psychotherapy, including language-based communication, for patients with HB, published until July 2023. The Cochrane risk-of-bias assessment tool and risk-of-bias in non-randomized studies of interventions were used to assess the methodological quality of the included studies.

RESULTS

Nine studies including 7 controlled clinical trials were included. Interventions encompassed 6 types: acceptance and commitment therapy, Adlerian counseling, integrated counseling, emotional freedom technique, art therapy, and psychotherapeutic programs for HB treatment. Except for the 2 types of counseling, all interventions were implemented in a group format, with total sessions ranging from 4 to 15 (average 8.11). Most interventions significantly improved HB symptoms compared to the waitlist or before-and-after comparisons. In the before-after comparison, the most frequently reported outcome of effectiveness was the HB Scale total score (100%, 6/6), followed by state anger (50%, 3/6), and state anxiety (50%, 2/4). For other outcomes, statistically significant positive results were reported in less than half of the cases, or there were only a small number of reported cases.

CONCLUSIONS

To our knowledge, this systematic review comprehensively investigated the effectiveness of psychotherapy for HB and found evidence for some psychotherapies not previously presented in the clinical practice guidelines for HB. However, methodological limitations, including the lack of an appropriate control group, make it difficult to obtain high-quality evidence on psychotherapy for HB.

An online mindfulness-based intervention for adults with Inflammatory Bowel Disease & psychological distress: A feasibility randomized controlled trial of the Mind4IBD program

OBJECTIVE

The bidirectional relationship between disease activity and mental health in inflammatory bowel disease (IBD) has prompted investigations into the efficacy of psychotherapies, such as mindfulness-based interventions (MBI), for improving biopsychosocial outcomes. Therefore, the aim is to examine the feasibility, acceptability, and preliminary efficacy of an online-delivered, self-directed MBI, adapted to individuals with IBD and psychological distress, in comparison to wait-list control (WLC).

METHODS

50 adults with IBD were randomized to WLC (N = 25) or intervention (N = 25) groups. The intervention (MIND4IBD program) consisted of six, weekly, 15-min videos (with guided meditations). Feasibility was examined through recruitment and retention rates, while acceptability was examined through intervention satisfaction ratings and qualitative feedback. Preliminary efficacy was examined using linear mixed models for group differences in outcomes between baseline and post-intervention.

RESULTS

Primary Outcomes. The retention rate for the WLC group was 92 %, while the retention rate for the intervention group was 48 %. However, 16 % of participants allocated to the intervention group never began the intervention, therefore this resulted in a retention rate of 71 % of participants who began the intervention. Acceptability was high with an average intervention satisfaction rating of 83/100.

SECONDARY OUTCOMES

When compared with the WLC, the MIND4IBD program improved total mindfulness levels (b = 0.29, 95 %CI [0.11,0.47], p = 0.004) with a large effect size (β = 0.54, b = 0.19, 95 %CI [0.04,0.34], p = 0.014). Themes based on participants' intervention feedback included: 1) beginning of journey with mindfulness, 2) the beneficial impact of mindfulness, 3) why adapting the intervention to IBD is important, 4) views on program delivery, and 5) mixed reactions to AI generated presenters.

CONCLUSION

MIND4IBD is feasible and acceptable for individuals with IBD and psychological distress. Participants' total mindfulness levels increased significantly in the intervention group compared to WLC. Most participants provided positive intervention feedback. These findings warrant a full-scale RCT to determine MIND4IBD's efficacy for IBD.

Development, feasibility, and preliminary effects of a culturally adapted, evidence-based, and theory-driven diabetes self-management programme for Chinese adults with type 2 diabetes receiving insulin injection therapy

AIMS

To describe the development of a culturally adapted, evidence-based, and theory-driven diabetes self-management programme for Chinese adults with type 2 diabetes receiving insulin injection therapy and to assess the feasibility, acceptability, and preliminary effects of the newly developed intervention.

METHODS

The Medical Research Council framework was adopted to guide the intervention development and a feasibility study. A prospective, two-arm, parallel-group, assessor-blinded randomised controlled trial was conducted. Participants were randomly allocated to receive either the newly developed intervention or parallel attention control contact from community nurses. Between-group differences in changes in outcome variables were analysed using the Mann-Whitney U test.

RESULTS

The newly developed intervention consists of one individual interview session, three group-based education sessions, and two telephone-based maintenance sessions. A total of 24 participants were recruited with the recruitment rate and overall retention rate of 77.4 % and 95.8 %, respectively. The results indicated that the intervention participants reported significantly greater improvements in self-efficacy (Hedge's g = 1.69) and self-management behaviours (Hedge's g = 3.24), and reductions in diabetes-related distress (Hedge's g = 1.49) compared with those in the control group (all p< 0.05).

CONCLUSION

The diabetes self-management programme was feasible and acceptable. The intervention showed promising patient-centred benefits. A future large-scale randomised controlled trial is warranted.

Protocol for a randomized controlled trial to evaluate the effectiveness of a telehealth group intervention to reduce perinatal depressive symptoms

BACKGROUND

Perinatal depression and anxiety (PDA) affect approximately 20 % of individuals and are associated with adverse outcomes, including preterm birth, low birth weight, and impaired cognitive development of the child. Telehealth may reduce access barriers to needed mental health services. However, lack of disseminated, standardized study protocols aimed at investigating the role of telehealth in reducing PDA symptoms limits the ability to compare findings across studies. The purpose of this paper is to provide a conceptual framework and a randomized controlled trial protocol (RCT) for use in future studies.

METHODS AND ANALYSIS

An RCT was designed to evaluate the effectiveness of a group videoconference intervention (VCI) to reduce PDA symptoms across pregnancy and postpartum period. Participants are randomly assigned to study groups: VCI + standard of care, or attention control (AC) + standard of care. Both groups have weekly one-hour group videoconference sessions for 9 weeks. The VCI groups are facilitated by a mental health professional using a manualized program based on mindfulness-based practices and cognitive behavioral therapy (MBCT). The AC groups are facilitated by a registered nurse using a manualized program for childbirth and parenting education. The primary outcomes are depressive symptoms as measured by the Edinburgh Postnatal Depression Scale (EPDS) and anxiety symptoms as measured by the Generalized Anxiety Disorder (GAD-7).

CONCLUSION

This RCT study protocol can be used as a standard approach to improve the ability to compare findings across studies, applied in any setting (e.g., rural or urban), and adapted to diverse communities.

TRIAL REGISTRATION

ClinicalTrials.govNCT03932760.

Mindfulness improves psychological health and supports health behaviour cognitions: Evidence from a pragmatic RCT of a digital mindfulness-based intervention

BACKGROUND

Mindfulness-based interventions can improve psychological health; yet the mechanisms of change are underexplored. This pre-registered remote RCT evaluated a freely accessible digital mindfulness programme aiming to improve well-being, mental health and sleep quality. Health behaviour cognitions were explored as possible mediators.

METHODS

Participants from 91 countries (N = 1247, Mage = 27.03 [9.04]) were randomized to 30 days of mindfulness practice or attention-matched control condition. Measures of well-being, depression, anxiety, stress, sleep quality, barriers self-efficacy, self-regulation and behavioural predictors (e.g., attitudes and behavioural intentions) were taken at baseline, 1-month (post-intervention) and 2-months (follow-up). Linear regression examined intervention effects between and within groups. Longitudinal mediation analyses explored indirect effects through health behaviour cognitions.

RESULTS

Three hundred participants completed post-intervention measures. Those receiving mindfulness training reported significantly better well-being (Mdifference = 2.34, 95%CIs .45-4.24, p = .016), lower depression (Mdifference = -1.47, 95%CIs -2.38 to -.56, p = .002) and anxiety symptoms (Mdifference = -.77, 95%CIs -1.51 to -.02, p = .045) than controls. Improvements in well-being and depression were maintained at follow-up. Intervention effects on primary outcomes were mediated by attitudes towards health maintenance and behavioural intentions. Mediating effects of attitudes remained when controlling for prior scores in models of depression and well-being.

CONCLUSIONS

Digital, self-administered mindfulness practice for 30 days meaningfully improved psychological health, at least partially due to improved attitudes towards health behaviours and stronger behavioural intentions. This trial found that digital mindfulness is a promising and scalable well-being tool for the general population, and highlighted its role in supporting health behaviours.

Development and testing of a videogame intervention for symptom management among 8-18 years old children with cancer: a study protocol

INTRODUCTION

Evidence shows that cancer treatment-related symptoms could be managed effectively in 8-18 years old children through Digital Health Interventions (DHIs), consequently improving their health-related quality of life (HRQOL). However, limited research is available about digitally mediated educative health interventions for children with cancer from lower-middle income countries like Pakistan. This study aims to develop a videogame intervention for children with cancer and test the clinical efficacy of the videogame concerning HRQOL and cancer treatment-related symptoms. Moreover, the following feasibility outcomes will be recorded: acceptability, appropriateness, cost, feasibility and intervention fidelity.

METHODS AND ANALYSIS

An exploratory sequential mixed methods design is used in this study. In the first phase of the study, we interviewed 28 participants (14 child-parent dyads) and assessed their symptom experiences affecting children's HRQOL. Moreover, their preferences for the development of the videogame were also elicited. Based on the findings from relevant literature and the interviews, we developed the videogame in collaboration with clinical and digital experts in the study's second phase. In the third phase of the study, a pilot randomised controlled trial will be conducted at a Tertiary Care Hospital in Karachi, Pakistan. There will be two groups: the intervention group and the control group. The intervention group children will receive the videogame application for 8 weeks, during which symptom management strategies will be taught to them. Children in the attention control group will receive weekly WhatsApp messages on healthy behaviours.The primary outcome will be the HRQOL of children, and the secondary outcome will be cancer symptoms frequency and distress. These outcomes will be assessed preintervention and 8 weeks post intervention. The feasibility outcomes will be assessed quantitatively and qualitatively through a questionnaire, videogame dashboard, interviews with a subset of intervention group child-parent dyads and a focus group discussion with nurses and doctors, post intervention, respectively.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Review Committee of the Aga Khan University (2022-6833-21251). Data are accessible only to the research team in a secure form. The findings will be disseminated through publications.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier NCT05796895, registered in April 2023.

Aerobic Physical Activity and Depression Among Patients With Cancer: A Systematic Review and Meta-Analysis

Importance

Depression is prevalent among patients with cancer, affecting their quality of life and survival. Aerobic physical activity (APA) is an effective strategy for managing depression in the general population, but its effectiveness for reducing depressive symptoms among patients with cancer requires further study.

Objective

To evaluate whether APA decreases depression severity in patients with cancer by synthesizing data from published randomized clinical trials (RCTs).

Data Sources

Six databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Scopus) were systematically searched for relevant citations published between January 1, 1980, and July 5, 2023.

Study Selection

This systematic review and meta-analysis included RCTs comparing APA interventions with usual care, waitlist control, or attention control for managing depression in patients with cancer, irrespective of age and cancer type.

Data Extraction and Synthesis

Two reviewers independently conducted screening and data extraction. Risk of bias was evaluated using the Cochrane Risk of Bias Tool, version 2. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. Standardized mean differences (SMDs) were calculated using a random-effects model. Data collection and analyses were performed between June 2022 and March 2024.

Main Outcomes and Measures

The primary outcome was severity of self-reported depression reported within 1 month of the end of intervention (short term). Secondary outcomes were severity of self-reported depression between 1 and 6 months post intervention (medium term) and between 6 and 12 months post intervention (long term).

Results

This meta-analysis included 25 RCTs with a total of 1931 adults with cancer (age range, 18-80 years). Ten RCTs (40%) had low risk of bias. Aerobic physical activity was associated with decreased self-reported depression among adults with cancer across the 25 included trials (n = 1931 participants; SMD, -0.38 [95% CI, -0.59 to -0.18]; P < .001; I2 = 76%). This decrease in depression scores was also significant for the secondary outcomes of long-term depression across 3 trials (n = 299 participants; SMD, -0.32 [95% CI, -0.60 to -0.04]; P = .03; I2 = 31%) but not for medium-term depression across 2 trials (n = 143 participants; SMD, -0.27 [95% CI, -0.60 to 0.06]; P = .10; I2 = 0%).

Conclusions and Relevance

In this systematic review and meta-analysis, APA was associated with modest short-term and long-term reductions of depression among adults with cancer. Future studies should discern the effectiveness of APA in combination with other strategies for managing depression across various populations of patients with cancer.

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis

Background

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.

Objectives

To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect.

Review design

Systematic review and network meta-analysis.

Eligibility criteria

Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention.

Main outcomes

Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.

Data sources

We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists.

Review methods

Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis).

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive.

Limitations

High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts.

Conclusions

Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence.

Future work

Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.

Study registration

This study is registered as PROSPERO CRD42019162195.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Design and Methods of the Early Age-Related Hearing Loss Investigation Randomized Controlled Trial

OBJECTIVE

Hearing loss has been identified as a major modifiable risk factor for cognitive decline. The Early Age-Related Hearing Loss Investigation (EARHLI) study will assess the mechanisms linking early age-related hearing loss (ARHL) and cognitive impairment.

STUDY DESIGN

Randomized, controlled, single-site, early phase II, superiority trial.

SETTING

Tertiary academic medical center.

PARTICIPANTS

One hundred fifty participants aged 55 to 75 years with early ARHL (severity defined as borderline to moderate) and amnestic mild cognitive impairment will be included.

INTERVENTIONS

Participants will be randomized 1:1 to a best practice hearing intervention or a health education control.

MAIN OUTCOME MEASURES

The primary study outcome is cognition measured by the Alzheimer Disease Cooperative Study-Preclinical Alzheimer Cognitive Composite. Secondary outcomes include additional measures of cognition, social engagement, and brain organization/connectivity.

RESULTS

Trial enrollment will begin in early 2024.

CONCLUSIONS

After its completion in 2028, the EARHLI trial should offer evidence on the effect of hearing treatment versus a health education control on cognitive performance, social engagement, and brain organization/connectivity in 55- to 75-year-old community-dwelling adults with early ARHL and amnestic mild cognitive impairment.

Ensuring Intervention Fidelity of an Attention Control Arm in a Multisite Randomized Controlled Trial

BACKGROUND

Intervention fidelity is a critical element of randomized controlled trials, yet reporting of intervention fidelity among attention control arms is limited. Lack of fidelity to attention control procedures can affect study outcomes by either overestimating or underestimating the efficacy of the intervention under examination.

OBJECTIVES

This brief report describes the approach researchers took to promote fidelity to the attention control arm of a pediatric palliative care randomized controlled trial funded by the National Institutes of Health.

METHODS

The Informational Meetings for Planning and Coordinating Treatment trial aims to determine the efficacy of a communication intervention that uses care team dyads (i.e., physicians partnered with nurses or advanced practice providers) to engage parents of children with cancer who have a poor prognosis in structured conversations about prognostic information, goals of care, and care planning. The intervention is compared with an attention control arm, which provides parents with structured conversations on common pediatric cancer education topics, such as talking to their child about their cancer, clinical trials, cancer treatment, side effects, and so forth. National Institutes of Health guidelines for assessing and implementing strategies to promote intervention fidelity were used to design (a) the attention control arm of a randomized controlled trial, (b) related attention control arm training, and (c) quality assurance monitoring.

RESULTS

Attention control study procedures were designed to mirror that of the intervention arm (i.e., same number, frequency, and time spent in study visits). Cluster randomization was used to allocate care team dyads to one arm of the randomized controlled trial. Care team dyads assigned to the attention control arm participated in online training sessions to learn attention control procedures, the different roles of research team members, and quality assurance methods. Fidelity to attention control procedures is assessed by both the interveners themselves and a quality assurance team.

DISCUSSION

Study design, training, and delivery are all critical to attention control fidelity. Baseline training often needs to be supplemented with booster training when time gaps occur between study start-up and implementation. Quality assurance procedures are essential to determine whether interveners consistently deliver attention control procedures correctly.

One-year cognitive outcomes from a multiple real-world skill learning intervention with older adults

OBJECTIVES

Novel skill learning has been shown to have cognitive benefits in the short-term (up to a few months). Two studies expanded on prior research by investigating whether learning multiple novel real-world skills simultaneously (e.g. Spanish, drawing, music composition), for a minimum of six hours a week, would yield 1-year cognitive gains.

METHOD

Following a 3-month multi-skill learning intervention, Study 1 (N = 6, Mage = 66 years, SDage = 6.41) and Study 2 (N = 27, Mage = 69 years, SDage = 7.12) participants completed follow-up cognitive assessments 3 months, 6 months, and one year after the intervention period. Cognitive assessments tested executive function (working memory and cognitive control) and verbal episodic memory.

RESULTS

Linear mixed-effects models revealed improvements in multiple cognitive outcomes from before the intervention to the follow-up timepoints. Specifically, executive function increased from pre-test to the 1-year follow-up for both studies (an effect driven mostly by cognitive control scores).

DISCUSSION

Our findings provide evidence that simultaneously learning real-world skills can lead to long-term improvements in cognition during older adulthood. Future work with diverse samples could investigate individual differences in gains. Overall, our findings promote the benefits of lifelong learning, namely, to improve cognitive abilities in older adulthood.

A randomised controlled trial of a nutrition and a decision support intervention to enable partnerships with families of critically ill patients

AIMS AND OBJECTIVES

The aim of the study was to investigate the effect of supporting family members to partner with health professionals on nutrition intakes and decision-making and to evaluate intervention and study feasibility.

BACKGROUND

Family partnerships can improve outcomes for critically ill patients and family members. Interventions that support families to engage with health professionals require evaluation.

DESIGN

A multi-centre, randomised, parallel group superiority Phase II randomised controlled trial.

METHODS

In nine intensive care units (ICUs) across three countries, critically ill patients ≥60 years, or those 55-59 years with advanced chronic diseases and expected ICU length of stay >72 h and their family member were enrolled between 9 May 2017 and 31 March 2020. Participants were randomised (1:1:1) to either a decision support or nutrition optimisation family-centred intervention, or usual care. Primary outcomes included protein and energy intake during ICU and hospital stay (nutrition intervention) and family satisfaction (decision support). Study feasibility was assessed as a composite of consent rate, intervention adherence, contamination and physician awareness of intervention assignment.

RESULTS

We randomised 135 patients/family members (consent rate 51.7%). The average rate of randomisation was 0.5 (0.13-1.53) per month. Unavailability (staff/family) was the major contributor to families not being approached for consent. Declined consent was attributed to families feeling overwhelmed (58/126, 46%). Pandemic visitor restrictions contributed to early study cessation. Intervention adherence for the decision support intervention was 76.9%-100.0% and for the nutrition intervention was 44.8%-100.0%. Nutritional adequacy, decisional conflict, satisfaction with decision-making and overall family satisfaction with ICU were similar for all groups.

CONCLUSIONS

Active partnerships between family members and health professionals are important but can be challenging to achieve in critical care contexts. We were unable to demonstrate the efficacy of either intervention. Feasibility outcomes suggest further refinement of interventions and study protocol may be warranted.

RELEVANCE TO CLINICAL PRACTICE

Interventions to promote family partnerships in critical illness are needed but require a greater understanding of the extent to which families want and are able to engage and the activities in which they have most impact.

REPORTING METHOD

This study has been reported following the Consolidated Standards of Reporting Trials (CONSORT) and the Template for Intervention Description and Replication (TIDieR) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were engaged in and contributed to the development and subsequent iterations of the two family-centred interventions use in this study.

CLINICAL TRIAL REGISTRATION NUMBER

Trial registration.

CLINICALTRIALS

gov, ID: NCT02920086. Registered on 30 September 2016. First patient enrolled on 9 May 2017 https://clinicaltrials.gov/ct2/results?cond=&term=NCT02920086&cntry=&state=&city=&dist=.

Variations in the Design and Use of Attention Control Groups in Type 2 Diabetes Randomized Controlled Trials: a Systematic Review

PURPOSE OF REVIEW

In type 2 diabetes (T2D) research, the phrase "attention control group" (ACGs) has been used with varying descriptions. We aimed to systematically review the variations in the design and use of ACGs for T2D studies.

RECENT FINDINGS

Twenty studies utilizing ACGs were included in the final evaluation. Control group activities had the potential to influence the primary outcome of the study in 13 of the 20 articles. Prevention of contamination across groups was not mentioned in 45% of the articles. Eighty-five percent of articles met or somewhat met the criteria for having comparable activities between the ACG and intervention arms. Wide variations in descriptions and the lack of standardization have led to an inaccurate use of the phrase "ACGs" when describing the control arm of trials, indicating a need for future research with focus on the adoption of uniform guidelines for use of ACGs in T2D RCTs.

An Evaluation of a Pesticide Training Program to Reduce Pesticide Exposure and Enhance Safety among Female Farmworkers in Nan, Thailand

BACKGROUND

Although exposure to chemical pesticides is known to cause negative effects on human health, farmers in Ban Luang, Nan, Thailand, continue to use them regularly to protect crops. This study focused on mothers who were engaged in farm tasks and had children between the ages of 0 to 72 months, with the objective of reducing pesticide exposure.

METHODS

This study was conducted from May 2020 to October 2020 in the Ban Fa and Ban Phi sub-districts in Ban Luang due to the high use of pesticides in these areas. A systematic random sampling technique was used to recruit 78 mothers exposed to pesticides. Thirty-nine mothers from Ban Fa district were randomly assigned to the intervention group and 39 from Ban Phi to the control group over a 3-month period. This study applied a pesticide behavioral change training program for the intervention group. To assess the effectiveness of the program, the study compared the results of a questionnaire regarding knowledge, attitude, and practice (KAP) and health beliefs related to pesticide exposure as well as the levels of acetylcholinesterase (AChE) and butyryl cholinesterase (BChE) enzymes, biomarkers of exposure to pesticides, before and after the intervention using ANCOVA statistical test. Furthermore, to evaluate the effectiveness of the intervention program, a paired t-test was used to investigate the in-home pesticide safety assessment.

RESULTS

After the intervention, we observed no significant change in AChE; however, a significant improvement in BChE (p < 0.05), a marker of short-term recovery, was observed. Pesticides can cause a reduction in AChE and BChE, however, after eliminating pesticides, BChE takes a shorter time (about 30-50 days) to recover than AChE (around 90-120 days). Therefore, increases in the measured concentrations of AChE and/or BChE suggest the presence of less chemicals from pesticides in the human body. The study also found a significant improvement in KAP and beliefs about chemical pesticide exposure after the intervention (p < 0.05). Furthermore, using a paired t-test, we found a significant increase in pesticide safety practices (p < 0.05) in the intervention group and a borderline significant increase regarding in-home safety (p = 0.051) in the control group.

CONCLUSIONS

Based on the results, the constructs of the intervention program were effective and could be applied in other agricultural areas in less developed countries. However, due to time limitations during the COVID-19 pandemic, further studies should be conducted to enable data collection over a longer time, with a larger number of subjects providing the ChE levels for the non-agricultural season.

"What I wanted to do was build myself back up and prepare": qualitative findings from the PERCEPT trial of prehabilitation during autologous stem cell transplantation in myeloma

BACKGROUND

The addition of qualitative methodology to randomised controlled trials evaluating complex interventions allows better understanding of contextualised factors and their potential influence on trial delivery and outcomes, as well as opportunities for feedback on trial participation to improve future trial protocols. This study explored the experiences of participation in cancer rehabilitation research during active cancer treatment. Participants were people living with haematological cancer myeloma, undergoing autologous stem cell transplantation (ASCT) recruited to the PERCEPT myeloma pilot trial.

METHODS

A qualitative semi-structured interview study, embedded within a pilot randomised controlled trial of a physiotherapist-led exercise intervention delivered before, during and after ASCT among people living with myeloma. Transcripts were analysed using reflexive thematic analysis.

RESULTS

Interviews from 16 trial participants (n = 8 intervention group; n = 8 control group; mean age 61 years, 56% male) were analysed. Four main themes were identified: (1) "It's not just beneficial for me, it's for people after me as well"; (2) Disparities in experience of recovery - expectations, feeling prepared and support; (3) "What I wanted to do was build myself back up and prepare"; (4) Active ingredients - participants' experience of the trial intervention. Participants reported both altruistic and perceived personal gain as motivators for enrolling in the trial. Disappointment caused by allocation to control arm may have led to participants seeking exercise elsewhere, indicating possible contamination of control condition. Disparities in experience of recovery from transplant were evident with intervention participants reporting greater trajectory of recovery.

CONCLUSIONS

The findings from this embedded qualitative study highlight numerous considerations required when designing pilot and efficacy trials of complex interventions. The addition of qualitative investigation offers greater understanding of motivations for participation, intervention mechanisms at play as well as effects of participation that may impact interpretation of quantitative outcomes.

TRIAL REGISTRATION

Qualitative findings from a prospectively registered pilot trial (ISRCTN15875290), registered 13/02/2019.

The long-term effects of primary school-based obesity prevention interventions in children: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis investigate the long-term effects of primary school-based obesity prevention interventions on body-mass index (and z-scores), waist circumference (and z-scores) and weight status.

METHODS

Four databases were searched for studies from date of inception until June 8th, 2021. We included randomized controlled trials (RCT) and non-RCTs investigating effects ≥12 months post-intervention of primary school-based interventions with intervention duration ≥6 months and containing a diet and/or physical activity component on outcomes of interest. Articles were assessed on risk of bias and methodological quality by RoB2 and ROBINS-I. Meta-analysis was performed and results were narratively summarized. Evidence quality was assessed with GRADE.

RESULTS

Nineteen studies were included, 9 were pooled in a meta-analysis. No long-term effects were found on body-mass index (+0.06 kg/m² ; CI95% = -0.38, 0.50; I²  = 66%), body-mass index z-scores (-0.08; CI95% = -0.20, 0.04; I²  = 36%), and waist circumference (+0.57 cm; CI95% = -0.62, 1.75; I²  = 13%). Non-pooled studies reported mixed findings regarding long-term effects on body-mass index, body-mass index z-scores and weight status, and no effects on waist circumference and waist circumference z-scores. Evidence certainty was moderate to very low.

DISCUSSION

No clear evidence regarding long-term effects of primary school-based interventions on obesity-related outcomes was found. Recommendations for further research and policy are discussed. Prospero registration ID: CRD42021240446.

Assessing the Suitability of a Virtual 'Pink Warrior' for Older Breast Cancer Survivors during COVID-19: A Pilot Study

The COVID-19 pandemic impacted the conduct of in-person physical activity (PA) interventions among older survivors of BC, who need such interventions to stay active and prevent functional decline. We tested the feasibility of virtually delivering an exergame-based PA intervention to older BC survivors. We enrolled 20 female BC survivors ≥55 years and randomly assigned them to two groups. The intervention group (Pink Warrior 2) received 12 weekly virtual exergame sessions with behavioral coaching, survivorship navigation support, and a Fitbit for self-monitoring. The control group received 12 weekly phone-based survivorship discussion sessions and wore a Mi Band 3. Feasibility was evaluated by rates of recruitment (≥0.92 participants/center/month), retention (≥80%), and group attendance (≥10 sessions), percentage of completed virtual assessments, and number of technology-related issues and adverse events. Intervention acceptability was measured by participants' ratings on a scale of 1 (strongly disagree) to 5 (strongly agree). The recruitment rate was 1.93. The retention and attendance rates were 90% and 88% (≥10 sessions), respectively. Ninety-six percent completed virtual assessments without an adverse event. Acceptability was high (≥4). The intervention met benchmarks for feasibility. Additional research is needed to further understand the impact of virtually delivered PA interventions on older BC survivors.

A narrative sequencing and mentalizing training for adults with autism: A pilot study

Adults diagnosed with autism experience difficulties with understanding the mental states of others, or themselves (mentalizing) and with adequately sequencing personal stories (narrative coherence). Given that the posterior cerebellum is implicated in both skills, as well as in the etiology of autism, we developed a narrative sequencing and mentalizing training for autistic adults. Participants with an official autism diagnosis were randomly assigned to a Training group (n = 17) or a waiting-list Control group (n = 15). The Training group took part in six weekly sessions in groups of three participants lasting each about 60 min. During training, participants had to (re)tell stories from the perspective of the original storyteller and answer questions that required mentalizing. We found significant improvements in mentalizing about others’ beliefs and in narrative coherence for the Training group compared to the Control group immediately after the training compared to before the training. Almost all participants from the Training group expressed beneficial effects of the training on their mood and half of the participants reported positive effects on their self-confidence in social situations. All participants recommended the current training to others. Results are discussed in light of cerebellar theories on sequencing of social actions during mentalizing. Further improvements to the program are suggested. Our results highlight the potential clinical utility of adopting a neuroscience-informed approach to developing novel therapeutic interventions for autistic populations.

Point‐of‐care tools to support optometric care provision to people with age‐related macular degeneration: A randomised, placebo‐controlled trial

Purpose

Age‐related macular degeneration (AMD) is a leading cause of vision impairment. This randomised placebo‐controlled trial investigated whether point‐of‐care tools can improve optometrists' AMD knowledge and/or care provision.

Methods

Australian optometrists (n = 31) completed a demographics survey and theoretical AMD case study multiple‐choice questions (MCQs) to assess their confidence in AMD care provision and AMD knowledge. Participants were then randomly assigned to one of three point‐of‐care tools (online ‘Classification of Age‐related macular degeneration and Risk Assessment Tool’ (CARAT), paper CARAT, or ‘placebo’) to use when providing care to their subsequent 5–10 AMD patients. Participants self‐audited the compliance of their AMD care to best practice for these patients, and a similar number of consecutive patients seen prior to enrolment. Post‐intervention, participants retook the AMD knowledge MCQs and confidence survey.

Results

A total of 29 participants completed the study. At the study endpoint, clinical confidence relative to baseline improved with the paper CARAT, relative to placebo, for knowledge of AMD risk factors, asking patients about these factors and referring for medical retinal sub‐specialist care. There were no between‐group differences for the change in AMD knowledge scores. Considering record documentation for patients with any AMD severity, there were no significant between‐group differences for documenting patient risk factors, AMD severity, clinical examination techniques or management. In a sub‐analysis, the change from baseline in compliance for documenting discussions about patient smoking behaviours for early AMD patients was higher with use of the online CARAT relative to placebo (p = 0.04). For patients with intermediate AMD, the change from baseline in documenting the risk of progression to late AMD was greater among practitioners who used the paper CARAT, relative to placebo (p = 0.04).

Conclusions

This study demonstrates that point‐of‐care clinical tools can improve practitioner confidence and aspects of the documentation of AMD clinical care by optometrists as assessed by self‐audit.

The clinical effectiveness of a physiotherapy delivered physical and psychological group intervention for older adults with neurogenic claudication: the BOOST randomised controlled trial

Background

Neurogenic claudication (NC) is a debilitating spinal condition affecting older adults’ mobility and quality of life.

Methods

A randomized controlled trial of 438 participants evaluated the effectiveness of a physical and psychological group intervention (BOOST program) compared to physiotherapy assessment and tailored advice (best practice advice [BPA]) for older adults with NC. Participants were identified from spinal clinics (community and secondary care) and general practice records and randomized 2:1 to the BOOST program or BPA. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data were also collected at 6 months. Other outcomes included ODI walking item, 6-minute walk test (6MWT), and falls. The primary analysis was intention-to-treat.

Results

The average age of participants was 74.9 years (standard deviation [SD] 6.0) and 57% (246/435) were female. There was no significant difference in ODI scores between treatment groups at 12 months (adjusted mean difference [MD]: −1.4 [95% confidence intervals (CI) −4.03, 1.17]), but, at 6 months, ODI scores favored the BOOST program (adjusted MD: −3.7 [95% CI −6.27, −1.06]). At 12 months, the BOOST program resulted in greater improvements in walking capacity (6MWT MD: 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD: −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio: 0.6 [95% CI 0.40, 0.98]) compared to BPA. No serious adverse events were related to either treatment.

Conclusions

The BOOST program substantially improved mobility for older adults with NC. Future iterations of the program will consider ways to improve long-term pain-related disability.

Clinical Trials Registration Number: ISRCTN12698674

The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain: Randomized Controlled Trial

Background

Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain.

Objective

This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP.

Methods

Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes.

Results

No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (≥11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group.

Conclusions

iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions.

Trial Registration

ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112

Intensive Daily Symptom and Function Monitoring Is Feasible and Acceptable to Women Undergoing First-Line Chemotherapy for Gynecologic Cancer

BACKGROUND

Women receiving chemotherapy for gynecologic cancer (GC) experience severe symptoms with associated functional changes. Understanding day-to-day symptom and function variation within and across chemotherapy treatment cycles could inform improved symptom management, but such studies are rare and may be infeasible in clinical care.

OBJECTIVE

The aim of this study was to evaluate feasibility and acceptability of daily symptom monitoring combined with objective and self-reported functional assessments every 21 days during active chemotherapy for GC.

METHODS

Thirty women enrolled in a prospective observational study during first-line chemotherapy completed a daily symptom and falls diary during their entire chemotherapy treatment period. Patient-reported outcomes and objective symptom and function testing were assessed before each chemotherapy appointment. Study outcomes included accrual and attrition rates, completion of study assessments, and qualitative perceptions of study participation.

RESULTS

Participants were 92% White, 60% had high school or higher education, 68% were married/partnered, and 62% had stage III or IV cancer at diagnosis. The study had an 83% accrual rate, 6.6% early withdrawal rate, and 17% total attrition rate. Missing assessments for prechemotherapy patient-reported outcomes and objective assessments ranged from 27% to 35% and 35% to 47% respectively, with a general decrease across cycles. Daily diary completion rate was 83% overall. Participants rated study participation positively.

CONCLUSIONS

Intensive daily symptom and function monitoring was feasible and acceptable to GC patients and may provide a sense of symptom controllability.

IMPLICATIONS FOR PRACTICE

Daily symptom and function monitoring in research studies may provide patients with information to support symptom discussions with the clinical team. Future work should develop proactive symptom management interventions using personalized symptom trajectories.

Guided self-determination intervention versus attention control for people with type 2 diabetes in outpatient clinics: a protocol for a randomised clinical trial

INTRODUCTION

In the management of type 2 diabetes, autonomy-supporting interventions may be a prerequisite to achieving more long-term improvement. Preliminary evidence has shown that the guided self-determination (GSD) method might have an effect on haemoglobin A1c and diabetes distress in people with type 1 diabetes. Previous trials were at risk of uncertainty. Thus, the objective is to investigate the benefits and harms of a GSD intervention versus an attention control group intervention in adults with type 2 diabetes.

METHODS AND ANALYSIS

This trial protocol is guided by the The Standard Protocol Items: Recommendations for International Trials Statement. We describe the protocol for a pragmatic randomised, dual-centre, parallel-group, superiority clinical trial testing a GSD intervention versus an attention control for people with type 2 diabetes in outpatient clinics. The participants (n=224) will be recruited from two diverse regions of Denmark. The experimental stepped-care intervention will consist of three to five GSD sessions lasting up to 1 hour with a trained GSD facilitator. The sessions will be conducted face to face, by video conference or over the telephone. The attention controls will receive three to five sessions lasting up to an hour with a communication-trained healthcare professional provided face to-face, by video conference, or over the telephone. Participants will be included if they have type 2 diabetes,>18 years old, are not pregnant. Participants will be assessed before randomisation, at 5-month, and 12-month follow-up, the latter being the primary. The primary outcome is diabetes distress. Secondary outcomes are quality of life, depressive symptoms and non-serious adverse events. Exploratory outcomes are haemoglobin A1c, motivation and serious adverse events. Data will be collected using REDCap and analysed using Stata V.16.

ETHICS AND DISSEMINATION

The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its latest form, International Harmonisation of Good Clinical Practice guidelines and the applicable regulatory requirement(s). The trial has been approved by the Danish Data Protection Agency (P-2020-864). The Ethics Committee of the Capital Region of Denmark reviewed the trial protocol, but exempted the trial protocol from full review (H-20003638). The results of the trial will be presented at the outpatient clinics treating people with type 2 diabetes, at national and international conferences as well as to associations for people with diabetes and their relatives.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04601311.