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Samar MR, Masood B, Zehra NE, Munir T, Soomro MY, Hameed MA, Ali I, Rashid YA. Outcomes of patients with anal cancer treated with definitive chemoradiation: A single centre experience. Ecancermedicalscience 2024; 18:1655. [PMID: 38425766 PMCID: PMC10901628 DOI: 10.3332/ecancer.2024.1655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Indexed: 03/02/2024] Open
Abstract
Background Anal cancers are uncommon neoplasms that make up to <1% of all tumours globally. Concurrent chemoradiation remains the standard of care treatment for patients who present with non-metastatic anal squamous cell carcinomas (ASCCs). Methods We aimed to evaluate the response rate and 2-year survival outcome of the definitive chemoradiation approach in patients with non-metastatic ASCCs of our population. We conducted a cross-sectional review of these patient populations who were treated and then followed after completion of treatment at our institute during the last 10 years. Results A total of 17 patients were enrolled after fulfillment of the eligibility criteria. The responses were documented in 16 patients through magnetic resonance imaging or computed tomography of the pelvis, done at 3 months of treatment completion. More than 80% of the patients had complete radiological responses. Among the surviving participants, the 2-year disease-free survival rate was found to be more than two-thirds. Approximately 20% of the study participants had disease recurrence during the subsequent clinic visits following treatment completion. Conclusion This review emphasises the impact of definitive chemo-radiation in achieving radiological and clinical responses in patients with non-metastatic ASCCs. Moreover, to our knowledge, this is the first review to highlight anal cancer's incidence and characteristics in Pakistan.
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Affiliation(s)
- Mirza Rameez Samar
- Department of Oncology, The Aga Khan University, Karachi 74600, Pakistan
| | - Bakhtawar Masood
- Department of Oncology, The Aga Khan University, Karachi 74600, Pakistan
| | - Nida E Zehra
- Department of Oncology, The Aga Khan University, Karachi 74600, Pakistan
| | - Tahir Munir
- Department of Anaesthesia, The Aga Khan University, Karachi 74600, Pakistan
| | | | | | - Insia Ali
- Department of Oncology, The Aga Khan University, Karachi 74600, Pakistan
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Raichurkar P, Denehy L, Solomon M, Koh C, Pillinger N, Hogan S, McBride K, Carey S, Bartyn J, Hirst N, Steffens D. Research Priorities in Prehabilitation for Patients Undergoing Cancer Surgery: An International Delphi Study. Ann Surg Oncol 2023; 30:7226-7235. [PMID: 37620526 PMCID: PMC10562336 DOI: 10.1245/s10434-023-14192-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Recently, the number of prehabilitation trials has increased significantly. The identification of key research priorities is vital in guiding future research directions. Thus, the aim of this collaborative study was to define key research priorities in prehabilitation for patients undergoing cancer surgery. METHODS The Delphi methodology was implemented over three rounds of surveys distributed to prehabilitation experts from across multiple specialties, tumour streams and countries via a secure online platform. In the first round, participants were asked to provide baseline demographics and to identify five top prehabilitation research priorities. In successive rounds, participants were asked to rank research priorities on a 5-point Likert scale. Consensus was considered if > 70% of participants indicated agreement on each research priority. RESULTS A total of 165 prehabilitation experts participated, including medical doctors, physiotherapists, dieticians, nurses, and academics across four continents. The first round identified 446 research priorities, collated within 75 unique research questions. Over two successive rounds, a list of 10 research priorities reached international consensus of importance. These included the efficacy of prehabilitation on varied postoperative outcomes, benefit to specific patient groups, ideal programme composition, cost efficacy, enhancing compliance and adherence, effect during neoadjuvant therapies, and modes of delivery. CONCLUSIONS This collaborative international study identified the top 10 research priorities in prehabilitation for patients undergoing cancer surgery. The identified priorities inform research strategies, provide future directions for prehabilitation research, support resource allocation and enhance the prehabilitation evidence base in cancer patients undergoing surgery.
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Affiliation(s)
- Pratik Raichurkar
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Linda Denehy
- Department of Health Services Research: Allied Health, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Colorectal Department, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Colorectal Department, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Neil Pillinger
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Sophie Hogan
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Nutrition and Dietetics Department, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Kate McBride
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Sharon Carey
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Nutrition and Dietetics Department, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Jenna Bartyn
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Nicholas Hirst
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.
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3
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Brown K, Solomon M, Ng KS, Sutton P, Koh C, White K, Steffens D. Development of a risk prediction tool for patients with locally advanced and recurrent rectal cancer undergoing pelvic exenteration: protocol for a mixed-methods study. BMJ Open 2023; 13:e075304. [PMID: 37648387 PMCID: PMC10471871 DOI: 10.1136/bmjopen-2023-075304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Pelvic exenteration (PE) surgery represents the only potentially curative treatment option for patients with locally advanced or recurrent rectal cancer (LARRC). Given the potential morbidity, whether or not PE should be recommended for an individual patient presents a major decisional conflict. This study aims to identify the outcomes of PE for which there is consensus among patients, carers and clinicians regarding their importance in guiding treatment decision-making, and to develop a risk prediction tool which predicts these outcomes. METHODS AND ANALYSIS This study will be conducted at a specialist PE centre, and employ a mixed-methods study design, divided into three distinct phases. In phase 1, outcomes of PE will be identified through a comprehensive systematic review of the literature (phase 1a), followed by exploration of the experiences of individuals who have undergone PE for LARRC and their carers (phase 1b, target sample size 10-20 patients and 5-10 carers). In phase 2, a survey of patients, their carers and clinicians will be conducted using Delphi methodology to explore consensus around the outcomes of highest priority and the level of influence each outcome should have on treatment decision-making. In phase 3 a, risk prediction tool will be developed using data from a single PE referral centre (estimated sample size 500 patients) to predict priority outcomes using multivariate modelling, and externally validated using data from an international PE collaboration. ETHICS AND DISSEMINATION Ethical approval has been granted for phases 1 and 2 (X22-0422 and 2022/ETH02659) and for maintenance of the database used in phase 3 (X13-0283 and HREC/13/RPAH/504). Informed consent will be obtained from participants in phases 1b and 2; a waiver of consent for secondary use of data in phase 3 will be sought. Study results will be submitted for publication in international and/or national peer reviewed journals. PROSPERO REGISTRATION NUMBER CRD42022351909.
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Affiliation(s)
- Kilian Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Paul Sutton
- Colorectal & Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Cherry Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate White
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- The Daffodil Centre, University of Sydney and Cancer Council NSW, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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O'Rinn SE, Barrett JFR, Parsons JA, Kingdom JC, D'Souza R. Engaging pregnant individuals and healthcare professionals in an international mixed methods study to develop a core outcome set for studies on placenta accreta spectrum disorder (COPAS): a study protocol. BMJ Open 2023; 13:e060699. [PMID: 37185194 PMCID: PMC10151908 DOI: 10.1136/bmjopen-2021-060699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) disorder is a life-threatening condition that may result in serious maternal complications, including mortality. The placenta which is pathologically adherent to the uterine wall, places individuals at high risk of major haemorrhage during the third stage of labour. Current research reports on PAS disorder outcomes have highly variable levels of information, which is therefore difficult for investigators to aggregate to inform practice. There is an urgent need to harmonise data collection in prospective studies to identify and implement best practices for management. One approach to standardise outcomes across any health area via the use of core outcome sets (COSs), which are consensus-derived standardised sets of outcomes that all studies for a particular condition should measure and report. This protocol outlines the steps for developing a COS for PAS disorder (COPAS). METHODS AND ANALYSIS This protocol outlines steps for the creation of COPAS. The first step, a systematic review, will identify all reported outcomes in the scientific literature. The second step will use qualitative one-on-one interviews to identify additional outcomes identified as important by patients and healthcare professionals that are not reported in the published literature. Outcomes from the first two steps will be combined to form an outcome inventory. This outcome inventory will inform the third step which is a Delphi survey that encourages agreement between patients and healthcare professionals on which outcomes are most important for inclusion in the COS. The fourth step, a consensus group meeting of representative participants, will finalise outcomes for inclusion in the PAS disorder COS. ETHICS AND DISSEMINATION This study has obtained Research Ethics Board approval from Sunnybrook Health Sciences Centre (#2338, #1488). We will aim to publish the study findings in an international peer-reviewed OBGYN journal. REGISTRATION DETAILS COMET Core Outcome Set Registration: https://www.comet-initiative.org/Studies/Details/1127. PROSPERO REGISTRATION NUMBER CRD42020173426.
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Affiliation(s)
- Susan E O'Rinn
- Outcomes & Evaluation, Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- DAN Women & Babies Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jon F R Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Janet A Parsons
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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5
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Retzer A, Sivell S, Scott H, Nelson A, Bulbeck H, Seddon K, Grant R, Adams R, Watts C, Aiyegbusi OL, Kearns P, Cruz Rivera S, Dirven L, Baddeley E, Calvert M, Byrne A. Development of a core outcome set and identification of patient-reportable outcomes for primary brain tumour trials: protocol for the COBra study. BMJ Open 2022; 12:e057712. [PMID: 36180121 PMCID: PMC9528585 DOI: 10.1136/bmjopen-2021-057712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Primary brain tumours, specifically gliomas, are a rare disease group. The disease and treatment negatively impacts on patients and those close to them. The high rates of physical and cognitive morbidity differ from other cancers causing reduced health-related quality of life. Glioma trials using outcomes that allow holistic analysis of treatment benefits and risks enable informed care decisions. Currently, outcome assessment in glioma trials is inconsistent, hindering evidence synthesis. A core outcome set (COS) - an agreed minimum set of outcomes to be measured and reported - may address this. International initiatives focus on defining core outcomes assessments across brain tumour types. This protocol describes the development of a COS involving UK stakeholders for use in glioma trials, applicable across glioma types, with provision to identify subsets as required. Due to stakeholder interest in data reported from the patient perspective, outcomes from the COS that can be patient-reported will be identified. METHODS AND ANALYSIS Stage I: (1) trial registry review to identify outcomes collected in glioma trials and (2) systematic review of qualitative literature exploring glioma patient and key stakeholder research priorities. Stage II: semi-structured interviews with glioma patients and caregivers. Outcome lists will be generated from stages I and II. Stage III: study team will remove duplicate items from the outcome lists and ensure accessible terminology for inclusion in the Delphi survey. Stage IV: a two-round Delphi process whereby the outcomes will be rated by key stakeholders. Stage V: a consensus meeting where participants will finalise the COS. The study team will identify the COS outcomes that can be patient-reported. Further research is needed to match patient-reported outcomes to available measures. ETHICS AND DISSEMINATION Ethical approval was obtained (REF SMREC 21/59, Cardiff University School of Medicine Research Ethics Committee). Study findings will be disseminated widely through conferences and journal publication. The final COS will be adopted and promoted by patient and carer groups and its use by funders encouraged. PROSPERO REGISTRATION NUMBER CRD42021236979.
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Affiliation(s)
- Ameeta Retzer
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Applied Research Centre, West Midlands, Birmingham, UK
| | - Stephanie Sivell
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Hannah Scott
- Cambridge Public Health, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | | | | | - Robin Grant
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard Adams
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Colin Watts
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Pamela Kearns
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Samantha Cruz Rivera
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
- Department of Neurology, Medical Centre Haaglanden, Den Haag, The Netherlands
| | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Applied Research Centre, West Midlands, Birmingham, UK
| | - Anthony Byrne
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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6
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Quirke F, Ariff S, Battin M, Bernard C, Bloomfield FH, Daly M, Devane D, Haas DM, Healy P, Hurley T, Kibet V, Kirkham JJ, Koskei S, Meher S, Molloy E, Niaz M, Ní Bhraonáin E, Okaronon CO, Tabassum F, Walker K, Biesty L. Core outcomes in neonatal encephalopathy: a qualitative study with parents. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001550. [PMID: 36053648 PMCID: PMC9328095 DOI: 10.1136/bmjpo-2022-001550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To identify the outcomes considered important to parents or caregivers of infants diagnosed with neonatal encephalopathy, hypoxic ischaemic encephalopathy or birth asphyxia in high-income and low- to middle-income countries (LMiCs), as part of the outcome-identification process in developing a core outcome set (COS) for the treatment of neonatal encephalopathy. DESIGN A qualitative study involving 25 semistructured interviews with parents or other family members (caregivers) of infants who were diagnosed with, and treated for, neonatal encephalopathy, hypoxic ischaemic encephalopathy or birth asphyxia. SETTING Interviews were conducted in high-income countries (HiCs) (n=11) by Zoom video conferencing software and in LMiCs (n=14) by phone or face to face. FINDINGS Parents identified 54 outcomes overall, which mapped to 16 outcome domains. The domains identified were neurological outcomes, respiratory outcomes, gastrointestinal outcomes, cardiovascular outcomes, motor development, cognitive development, development (psychosocial), development (special senses), cognitive development, development (speech and social), other organ outcomes, survival/living outcomes, long-term disability, hospitalisation, parent-reported outcomes and adverse events. CONCLUSIONS This study provides insight into the outcomes that parents of infants diagnosed with neonatal encephalopathy have identified as the most important, to be considered in the process of developing a COS for the treatment of neonatal encephalopathy. We also provide description of the processes employed to ensure the inclusion of participants from LMiCs as well as HiCs.
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Affiliation(s)
- Fiona Quirke
- Health Research Board - Neonatal Encephalopathy PhD Training Network (NEPTuNE), Trinity College Dublin, Dublin, Ireland .,Health Research Board-Trials Methodology Research Network (HRB-TMRN), Galway, Ireland.,School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Shabina Ariff
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Pakistan
| | | | - Caitlin Bernard
- Department of Obstetrics and Gynecology, Indiana University, Bloomington, Indiana, USA
| | | | - Mandy Daly
- Advocacy and Policymaking Irish Neonatal Health Alliance, Wicklow, Ireland
| | - Declan Devane
- Health Research Board - Neonatal Encephalopathy PhD Training Network (NEPTuNE), Trinity College Dublin, Dublin, Ireland.,Health Research Board-Trials Methodology Research Network (HRB-TMRN), Galway, Ireland.,School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,Evidence Synthesis Ireland, National University of Ireland Galway, Galway, Ireland.,Cochrane Ireland, National Univeristy of Ireland Galway, Galway, Ireland
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Bloomington, Indiana, USA
| | - Patricia Healy
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,Evidence Synthesis Ireland, National University of Ireland Galway, Galway, Ireland
| | - Tim Hurley
- Health Research Board - Neonatal Encephalopathy PhD Training Network (NEPTuNE), Trinity College Dublin, Dublin, Ireland.,Department of Paediatric and Child Health, Tallaght University Hospital (TUH), Dublin, Ireland
| | | | - Jamie J Kirkham
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | - Eleanor Molloy
- Health Research Board - Neonatal Encephalopathy PhD Training Network (NEPTuNE), Trinity College Dublin, Dublin, Ireland.,Paediatrics, Trinity College Dublin, Dublin, Ireland.,Paediatrics, Tallaght Hospital, Dublin, Ireland
| | - Maira Niaz
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Karen Walker
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Linda Biesty
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,Evidence Synthesis Ireland, National University of Ireland Galway, Galway, Ireland.,Qualitative Research in Trials Centre (QUESTS), National University of Ireland Galway, Galway, Ireland
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7
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Mee H, Castano Leon A, Timofeev I, Adeleye A, Devi I, Marklund N, Muehlschlegel S, Bond K, Clement C, Grieve K, Owen N, Whiting G, Turner C, Rubiano A, Shukla D, Paul M, Allanson J, Pomeroy V, Viaroli E, Warburton E, Wells A, Hawryluk G, Helmy A, Anwar F, Honeybul S, Hutchinson P, Kolias A. Study Protocol: Core Outcome Set for cranioplasty following stroke or TBI 'COAST Study'. JMIR Res Protoc 2022; 12:e37442. [PMID: 35759752 PMCID: PMC10152332 DOI: 10.2196/37442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/15/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Core Outcome sets (COS) are important and necessary as they help standardize reporting in research studies. Cranioplasty following traumatic brain injury or stroke is becoming increasingly common leading to an ever growing clinical and research interest especially regarding the optimal material, cost-effectiveness, and timing of cranioplasty concerning neurological recovery and complications. Consequently, heterogeneous reporting of outcomes from such diverse studies has led to a limited meta-analysis ability, with the ongoing risk of outcome reporting bias. OBJECTIVE To define a standardized COS for reporting in all future TBI and stroke cranioplasty studies. METHODS An international steering committee has been formed to guide the development of the COS. In addition, recommendations from other clinical initiatives such as COMET (Core Outcomes and Effectiveness Trials) and OMERACT (Outcome Measures in Rheumatology) have been adhered to. The first phase of the project is data-collection through a systematic review and qualitative study. The second phase will be the COS-formation through a Delphi survey and consensus meeting. A definition of consensus will be decided and agreed upon before the Delphi survey begins to avoid bias, which is planned for the end of 2021. RESULTS The development of a cranioplasty COS that can be applied in future research, helping to align future studies, building an increased understanding of cranioplasty and its impact on a patients function and recovery. CONCLUSIONS This study should result in consensus on a COS for cranioplasty following TBI or stroke. CLINICALTRIAL The study has been registered on the Core Outcome Measures in Effectiveness Trials (COMET) database for COS development.
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Affiliation(s)
- Harry Mee
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Box 167, A blockAddenbrookes Hospital, Cambridge, GB.,Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Box 167, Level 4, AblockAddenbrookes Hosital, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
| | | | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | | | - Indira Devi
- Department of Neurosurgery, Nimhans, Bangalore, IN
| | | | | | - Katie Bond
- Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Clare Clement
- Bristol Trials Centre, Bristol Medical School, Bristol, GB
| | - Kirsty Grieve
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Nicola Owen
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Gemma Whiting
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Carole Turner
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
| | - Andres Rubiano
- Department of Neurosciences and Neurosurgery, Valle Salud IPS Network, Cali, CO
| | | | | | - Judith Allanson
- Division of Anaesthesia, University of Cambridge, Cambridge, GB
| | - Valerie Pomeroy
- Neurorehabilitation Department, University of East Anglia, Norwich, GB
| | - Edoardo Viaroli
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Elizabeth Warburton
- Division of Stroke Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Adam Wells
- University of Adelaide, The Royal Adelaide Hospital, Adelaide, AU
| | | | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Fahim Anwar
- Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | | | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
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8
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Holl DC, Chari A, Iorio-Morin C, Dammers R, van der Gaag NA, Kolias AG, Hutchinson PJ, Edlmann E. Study Protocol on Defining Core Outcomes and Data Elements in Chronic Subdural Haematoma. Neurosurgery 2021; 89:720-725. [PMID: 34318894 PMCID: PMC8440066 DOI: 10.1093/neuros/nyab268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Core Outcome Sets (COSs) are necessary to standardize reporting in research studies. This is urgently required in the field of chronic subdural hematoma (CSDH), one of the most common disease entities managed in neurosurgery and the topic of several recent trials. To complement the development of a COS, a standardized definition and baseline Data Elements (DEs) to be collected in CSDH patients, would further improve study quality and comparability in this heterogeneous population. OBJECTIVE To, first, define a standardized COS for reporting in all future CSDH studies; and, second, to identify a unified CSDH Definition and set of DEs for reporting in future CSDH studies. METHODS The overall study design includes a Delphi survey process among 150 respondents from 2 main stakeholder groups: healthcare professionals or researchers (HCPRs) and Patients or carers. HCPR, patients and carers will all be invited to complete the survey on the COS, only the HCPR survey will include questions on definition and DE. EXPECTED OUTCOMES It is expected that the COS, definition, and DE will be developed through this Delphi survey and that these can be applied in future CSDH studies. This is necessary to help align future research studies on CSDH and to understand the effects of different treatments on patient function and recovery. DISCUSSION This Delphi survey should result in consensus on a COS and a standardized CSDH Definition and DEs to be used in future CSDH studies.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Aswin Chari
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | | | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Niels A van der Gaag
- University Neurosurgical Centre Holland (UNCH), Leiden University Medical Centre, Haaglanden Medical Centre, Haga Teaching Hospital, the Netherlands
| | - Angelos G Kolias
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Ellie Edlmann
- Department of Neurosurgery, South West Neurosurgical Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK.,Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
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9
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Liu M, Gao Y, Yuan Y, Shi S, Yang K, Lu C, Wu J, Zhang J, Tian J. Inconsistency and low transparency were found between core outcome set protocol and full text publication: a comparative study. J Clin Epidemiol 2020; 131:59-69. [PMID: 33227446 DOI: 10.1016/j.jclinepi.2020.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 10/16/2020] [Accepted: 11/13/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of the study was to assess inconsistencies between individual protocols and associated full-text publications in the development of core outcome sets (COSs). STUDY DESIGN AND SETTING Protocols and subsequent full-text publications were retrieved by searching the following electronic databases: PubMed, Embase, Web of Science, and the Core Outcome Measures in Effectiveness Trials database from inception to October 1, 2019. We summarized changes in the general and methodological characteristics by comparing the protocols with the full-text publications and reported change as information frequency and proportion. RESULTS A total of 24 protocols and 32 corresponding full-text publications that encompassed 14 study topics were identified from databases. In the identified initial list of outcomes, five COSs (20.8%) changed the included study type, none of which explained the reasons for these changes. In addition, eight COSs showed inconsistencies between the protocols and full-text publications in the searched databases, of which, only two studies explained the reasons for these changes. Compared with the protocols, three COSs changed the number of Delphi rounds, eight COSs changed the participants (stakeholder groups), and three COSs changed the consensus definition of the Delphi survey. Only two COSs explained the reason for changing the number of Delphi rounds, and none of the studies explained why the participants changed. For the face-to-face consensus meeting, we found that nine COSs changed the participants and none explained the reasons for these changes. CONCLUSION Our study found many inconsistencies between protocols and the full-text publications concerning COS development. These inconsistencies related to the included study types, databases searched, Delphi surveys, and face-to-face consensus meetings. As it is necessary to publish protocols before developing COSs, transparency regarding any changes to the methods is needed.
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Affiliation(s)
- Ming Liu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou 730000, China
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou 730000, China
| | - Yuan Yuan
- Gansu University of Chinese Medicine, Lanzhou 730000, China
| | - Shuzhen Shi
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou 730000, China
| | - Kelu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Cuncun Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou 730000, China
| | - Jiarui Wu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medical, Beijing University of Chinese Medicine, Beijing 100105, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China.
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou 730000, China.
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10
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Clinical characteristics and prognosis of anal squamous cell carcinoma: a retrospective audit of 144 patients from 11 cancer hospitals in southern China. BMC Cancer 2020; 20:679. [PMID: 32693779 PMCID: PMC7372759 DOI: 10.1186/s12885-020-07170-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/12/2020] [Indexed: 11/25/2022] Open
Abstract
Background The incidence of anal squamous cell carcinoma (SCC) has been steadily growing globally in the past decade. Clinical data on anal SCC from China are rare. We conducted this study to describe the clinical and epidemiological characteristics of anal SCC in China and explore prognostic factors of outcomes among patients with anal SCC. Methods We audited demographic characteristics, relevant symptoms, risk factors, treatment modalities and outcomes for patients diagnosed with anal SCC at 11 medical institutions in China between January 2007 and July 2018. Results A total of 144 patients (109 females) were diagnosed with SCC during this period. Median age at initial diagnosis was 52.0 (interquartile range: 46.0–61.8) years. The most common symptoms were bleeding (n = 93, 64.6%), noticing a lump (n = 49, 34.0%), and pain (n = 47, 32.6%). The proportion of patients at the American Joint Committee on Cancer (AJCC) stages I-IV were 10 (6.9%), 22 (15.3%), 61 (42.4%) and 8 (5.6%), respectively, and AJCC stages in 43 (29.9%) patients were unknown. Thirty-six patients (25.0%) underwent abdominoperineal resection initially. Univariable analysis showed that T stage predicted recurrence-free survival (RFS) (Hazard ratio [HR] = 3.03, 95% Confidence interval [CI]: 1.10–8.37, p = 0.032), and age group (HR = 2.90, 95% CI: 1.12–7.49, p = 0.028), AJCC stage (HR = 4.56, 95% CI: 1.02–20.35, p = 0.046), and N stage (HR = 3.05, 95% CI: 1.07–8.74, p = 0.038) predicted overall survival (OS). Conclusions T stage was identified as prognostic factor of RFS, and age, AJCC stage, and N stage were identified as prognostic factors of OS. Improving symptom awareness and earlier presentation among patients potentially at risk for anal SCC should be encouraged. Familiarity with the standard treatment among health care providers in China should be further improved.
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11
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Lee MJ, Coe PO, O'Donoghue R, Peirson M, Saha A. Variation in descriptors of patient characteristics in randomized clinical trials of peptic ulcer repair: a systematic review. Br J Surg 2020; 107:1570-1579. [PMID: 32671830 DOI: 10.1002/bjs.11771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/02/2020] [Accepted: 05/14/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The ability to compare findings across surgical research is important. Inadequate description of participants, interventions or outcomes could lead to bias and inaccurate assessment of findings. The aim of this study was to assess consistency of description of participants using studies comparing laparoscopic and open repair of peptic ulcer as an example. METHODS This systematic review is reported in line with the PRISMA checklist. Searches of MEDLINE and Embase databases were performed to identify studies comparing laparoscopic and open repair of perforated peptic ulcer in adults, published in the English language. Manuscripts were dual-screened for eligibility. Full texts were retrieved and dual-screened for inclusion. Data extracted from studies included descriptors of participants in studies from tables and text. Descriptors were categorized into conceptual domains by the research team, and coverage of each domain by study was tabulated. RESULTS Searches identified 2018 studies. After screening, 37 full texts were retrieved and 23 studies were included in the final synthesis. A total of 76 unique descriptors were identified. These were classified into demographics (11 descriptors), vital signs (9 descriptors), disease-specific characteristics (10 descriptors), presentation and pathway factors (4 descriptors), risk factors (8 descriptors), laboratory tests (14 descriptors) and baseline health (28 descriptors). The number of descriptors in a single study ranged from three to 31. All studies reported at least one demographic descriptor. Laboratory tests was the least frequently described domain. CONCLUSION Study participants are described inconsistently in studies of a single example surgical condition.
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Affiliation(s)
- M J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - P O Coe
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - M Peirson
- Department of General Surgery, Ysbyty Gwynedd Hospital, Bangor, UK
| | - A Saha
- Department of General Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
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12
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Baddeley E, Bravington A, Johnson M, Currow DC, Murtagh FE, Boland E, Obita G, Nelson A, Seddon K, Oliver A, Noble S, Boland J. Development of a core outcome set to use in the research and assessment of malignant bowel obstruction: protocol for the RAMBO study. BMJ Open 2020; 10:e039154. [PMID: 32595168 PMCID: PMC7322279 DOI: 10.1136/bmjopen-2020-039154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Studies regarding the management of malignant bowel obstruction (MBO) report conflicting findings. This is partly due to different outcome measures being used to evaluate severity of MBO and the response to treatments. Furthermore, current outcome measures focus mainly on measurable physiological parameters which may not correlate strongly with patient-defined quality of life. The development of core outcome sets allows a consistent approach to evaluating clinical conditions taking into consideration patient, healthcare professional and researcher viewpoints. It follows an internationally recognised standard methodology. We present a protocol for the development of a core outcome set for Research and Assessment of MBO (RAMBO). METHODS RAMBO is a multicentre study, comprising of four phases: a systematic review to examine current scope of outcome measures associated with MBO (phase I). Interviews with patients, companions and healthcare professionals will explore priorities and preferences for care and outcomes (phase II). An expert panel meeting will collate the findings into a set of outcomes (phase III), refined by consensus through a Delphi survey with key stakeholders (phase IV). The final set of outcomes will be ratified at a consensus meeting. Each step will actively include patient partners. Thematic analysis and descriptive statistics will be used to analyse qualitative and quantitative data, respectively. ETHICS AND DISSEMINATION Ethical approval was obtained (Wales REC 5, REF: 19/LO/1876). Study participants and relevant stakeholders will be updated with newsletters and a lay summary at the end of the study. Abstracts will be submitted to national and international conferences, result papers will be submitted to peer-reviewed, open access journals. TRIAL AND PROSPERO REGISTRATION NUMBERS Core Outcome Measures in Effectiveness Trials (1402); Systematic Literature Review (CRD42019150648); Rapid Review (CRD42020176393).
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Affiliation(s)
- Elin Baddeley
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Cardiff, UK
| | - Alison Bravington
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - David C Currow
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Elaine Boland
- Queen's Centre for Oncology and Haematology, Hull, UK
| | | | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Cardiff, UK
| | - Alfred Oliver
- Consumer Liaison Group, National Cancer Research Institute, London, UK
- Trans-Humber Consumer Research Panel, Hull, UK
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Cardiff, UK
| | - Jason Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
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13
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Lang KM, Harrison KL, Williamson PR, Huntly BJP, Ossenkoppele G, Geissler J, Bereczky T, Hernández-Rivas JM, Chevrou-Séverac H, Goodbody R, Schulze-Rath R, Bullinger L. Core outcome set measurement for future clinical trials in acute myeloid leukemia: the HARMONY study protocol using a multi-stakeholder consensus-based Delphi process and a final consensus meeting. Trials 2020; 21:437. [PMID: 32460828 PMCID: PMC7251906 DOI: 10.1186/s13063-020-04384-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Acute myeloid leukemia (AML) is the most common acute leukemia in adults and has an unacceptably low cure rate. In recent years, a number of new treatment strategies and compounds were developed for the treatment of AML. There were several randomized controlled clinical trials with the objective to improve patients’ management and patients’ outcome in AML. Unfortunately, these trials are not always directly comparable since they do not measure the same outcomes, and currently there are no core outcome sets that can be used to guide outcome selection and harmonization in this disease area. The HARMONY (Healthcare Alliance for Resourceful Medicine Offensive against Neoplasms in Hematology) Alliance is a public-private European network established in 2017 and currently includes 53 partners and 32 associated members from 22 countries. Amongst many other goals of the HARMONY Alliance, Work Package 2 focuses on defining outcomes that are relevant to each hematological malignancy. Accordingly, this pilot study will be performed to define a core outcome set in AML. Methods The pilot study will use a three-round Delphi survey and a final consensus meeting to define a core outcome set. Participants will be recruited from different stakeholder groups, including patients, clinicians, regulators and members of the European Federation of Pharmaceutical Industries and Associations. At the pre-Delphi stage, a literature research was conducted followed by several semi-structured interviews of clinical public and private key opinion leaders. Subsequently, the preliminary outcome list was discussed in several multi-stakeholder face-to-face meetings. The Delphi survey will reduce the preliminary outcome list to essential core outcomes. After completion of the last Delphi round, a final face-to-face meeting is planned to achieve consensus about the core outcome set in AML. Discussion As part of the HARMONY Alliance, the pilot Delphi aims to define a core outcome set in AML on the basis of a multi-stakeholder consensus. Such a core outcome set will help to allow consistent comparison of future clinical trials and real-world evidence research and ensures that appropriate outcomes valued by a range of stakeholders are measured within future trials.
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Affiliation(s)
- Katharina M Lang
- Charité University Medicine, Chariteplatz 1, Berlin, 10117, Germany.
| | - Kathryn L Harrison
- NICE, National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU, UK
| | - Paula R Williamson
- MRC North West Hub for Trials Methodology Research, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | | | - Gert Ossenkoppele
- VU University Medical Center, De Boelelaan 1105, Amsterdam, 1081 HV, Netherlands
| | - Jan Geissler
- Patvocates, Am Rothenanger 1b, Riemerling, 85521, Germany
| | - Tamàs Bereczky
- Patvocates, Am Rothenanger 1b, Riemerling, 85521, Germany
| | | | | | | | | | - Lars Bullinger
- Charité University Medicine, Chariteplatz 1, Berlin, 10117, Germany
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14
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Abstract
Purpose of Review With advances in radiation therapy (RT) techniques for rectal and anal cancers allowing for the modulation of critical normal tissues, there has been an increased emphasis on improving the quality of life (QOL) of cancer survivors. Herein, we review the literature to examine the impact of RT on QOL and patient reported outcomes (PROs) to better inform providers about the challenges of survivorship. Recent Findings Large systematic reviews, recent studies and long-term follow-up of pivotal clinical trials have shown that RT impacts QOL, particularly fecal continence and sexual function. Modern preoperative RT techniques allow for decreased dose to organs-at-risk will likely improve QOL. Summary RT, though critical in the treatment of rectal and anal cancer, has a profound impact on QOL for some patients. Recent studies have included PROs and validated QOL metrics to better inform providers and patients.
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15
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Killeen SL, O'Brien EC, Jacob CM, O'Reilly SL, Hanson M, McAuliffe FM. PREgnancy Nutrition: A protocol for the development of a Core Outcome Set (PRENCOS). Int J Gynaecol Obstet 2019; 147:134-139. [PMID: 31571233 DOI: 10.1002/ijgo.12953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/06/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a Core Outcome Set (COS) for pregnancy nutrition research that is relevant to varied stakeholders and resource settings. METHODS This study has three distinct phases. The first phase involves generating a list of outcomes for consideration for the COS. This includes a systematic review of studies evaluating nutrition during pregnancy where all outcomes reported in relevant literature will be extracted. Qualitative interviews with currently or previously pregnant women will also be conducted. This step will supplement the findings of the systematic review by identifying additional outcomes of importance to this stakeholder group. In the second phase of the study, healthcare professionals, researchers, and mothers from various international resource settings will be invited to participate in a two-round modified Delphi survey. The aim of the survey is to gain consensus on which outcomes are most important to include in the COS. Finally, a face-face consensus meeting will be held with a select group of participants to finalize the COS. CONCLUSION This COS will support standardization of outcome reporting in pregnancy nutrition research and ensure that selected outcomes are considered important by a variety of stakeholders. This will enhance the evidence behind nutrition interventions in pregnancy to improve outcomes for pregnant women.
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Affiliation(s)
- Sarah Louise Killeen
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Eileen C O'Brien
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Chandni Maria Jacob
- Institute of Developmental Sciences, University of Southampton, Southampton, UK.,Academic Unit of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton and University of Southampton, Southampton, UK
| | - Sharleen L O'Reilly
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland.,UCD Institute of Food and Health, School of Agriculture and Food Science, University College Dublin, Dublin, Ireland
| | - Mark Hanson
- Institute of Developmental Sciences, University of Southampton, Southampton, UK.,Academic Unit of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton and University of Southampton, Southampton, UK
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
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16
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Savoie MB, Laffan A, Brickman C, Daniels B, Levin A, Rowen T, Smith J, Van Blarigan EL, Hope TA, Berry-Lawhorn JM, Anwar M, Van Loon K. A multi-disciplinary model of survivorship care following definitive chemoradiation for anal cancer. BMC Cancer 2019; 19:906. [PMID: 31510960 PMCID: PMC6737598 DOI: 10.1186/s12885-019-6053-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
Following definitive chemoradiation for anal squamous cell carcinoma (ASCC), patients face a variety of chronic issues including: bowel dysfunction, accelerated bone loss, sexual dysfunction, and psychosocial distress. The increasing incidence of this disease, high cure rates, and significant long-term sequelae warrant increased focus on optimal survivorship care following definitive chemoradiation. In order to establish our survivorship care model for ASCC patients, a multi-disciplinary team of experts performed a comprehensive literature review and summarized best practices for the multi-disciplinary management of this unique patient population. We reviewed principle domains of our survivorship approach: (1) management of chronic toxicities; (2) sexual health; (3) HIV management in affected patients; (4) psychosocial wellbeing; and (5) surveillance for disease recurrence and survivorship care delivery. We provide recommendations for the optimization of survivorship care for ASCC patients can through a multi-disciplinary approach that supports physical and psychological wellness.
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Affiliation(s)
- Marissa B Savoie
- School of Medicine, University of California, San Francisco, USA
| | - Angela Laffan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Cristina Brickman
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, USA
| | - Bevin Daniels
- Department of Physical Therapy, University of California, San Francisco, USA
| | - Anna Levin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Psycho-Oncology, University of California, San Francisco, USA
| | - Tami Rowen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | - James Smith
- Department of Urology, University of California, San Francisco, USA
| | - Erin L Van Blarigan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Urology, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - J Michael Berry-Lawhorn
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA
| | - Mekhail Anwar
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA.
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA.
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17
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Peiffert D. [Anal channel cancer: customization of dose, volume and breaching]. Cancer Radiother 2019; 23:773-777. [PMID: 31471250 DOI: 10.1016/j.canrad.2019.07.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
The conservative treatment of squamous cell carcinoma of anal canal by irradiation is recommended as first indication. Despite its rarity, significant improvements were obtained by retrospective or prospective clinical studies these 20 past years, evaluating concomitant chemotherapy and IMRT. Nevertheless, the individualisation of the treatment, over dose distribution, has poor data available. Fractionation remains classic (1.8-2.0Gy/Fr), but the optimal dose level remains under discussion. The strategy concerning the volumes and doses for the prophylactic volumes remains under discussion. This paper will describe the data published, and the recommendations of working Groups, and the main options under evaluation. To conclude, today only the absence of gap is recommended, the benefit of a one-step schedule reducing the treatment time, then increasing local control and survival, but personalised schedules remain under investigation.
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Affiliation(s)
- D Peiffert
- Département de radiothérapie, institut de cancérologie de Lorraine Alexis-Vautrin, avenue de Bourgogne, 54511 Vandoeuvre-les-Nancy, France.
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18
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Sodergren SC, Gilbert A, Darlington AS, Vassiliou V. Anal Cancer: Putting Health-Related Quality of Life at the Forefront. Clin Oncol (R Coll Radiol) 2019; 31:69-71. [PMID: 30415785 DOI: 10.1016/j.clon.2018.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 11/20/2022]
Affiliation(s)
- S C Sodergren
- School of Health Sciences, University of Southampton, Southampton, UK.
| | - A Gilbert
- Leeds Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - A-S Darlington
- School of Health Sciences, University of Southampton, Southampton, UK
| | - V Vassiliou
- Bank of Cyprus Oncology Centre, Nicosia, Cyprus
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19
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Fish R, Sanders C, Adams R, Brewer J, Brookes ST, DeNardo J, Kochhar R, Saunders MP, Sebag-Montefiore D, Williamson PR, Renehan AG. A core outcome set for clinical trials of chemoradiotherapy interventions for anal cancer (CORMAC): a patient and health-care professional consensus. Lancet Gastroenterol Hepatol 2018; 3:865-873. [PMID: 30507470 DOI: 10.1016/s2468-1253(18)30264-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 12/17/2022]
Abstract
Chemoradiotherapy is the primary treatment for patients with squamous cell carcinoma of the anus, but variations in the reported outcomes have restricted between-study comparisons. Treatment-related morbidity is considerable; however, no trial has comprehensively quantified long-term side-effects or quality of life. Therefore, we established the first international health-care professional and patient consensus to develop a core outcome set, using the Core Outcome Measures in Effectiveness Trials method. We used the results from our previous systematic review and combined them in this Review with patient interviews to derive a comprehensive list of outcomes, followed by a two-round Delphi survey completed by 149 participants (55 patients and 94 health-care professionals) from 11 countries. The Delphi results were discussed at a consensus meeting of health-care professionals and patients. Agreement was reached on 19 outcomes across four domains: disease activity, survival, toxicity, and life impact. Implementation of the Core Outcome Research Measures in Anal Cancer (CORMAC) set in future trials will serve as a framework to achieve standardisation, facilitate selection of health-area-specific evaluation tools, reduce redundancy of outcome lists, allow between-study comparisons, and ultimately enhance the relevance of trial findings to health-care professionals, trialists, and patients.
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Affiliation(s)
- Rebecca Fish
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK.
| | - Caroline Sanders
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Richard Adams
- Centre for Trials Research, Cardiff University School of Medicine, Cardiff, UK; Velindre Cancer Centre, Cardiff, UK
| | - Julie Brewer
- Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK
| | - Sara T Brookes
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Jill DeNardo
- Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK
| | - Rohit Kochhar
- Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK
| | - Mark P Saunders
- Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK
| | | | - Paula R Williamson
- Medical Research Council North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Andrew G Renehan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Manchester Cancer Research Centre and National Institute for Health Research, Manchester Biomedical Research Centre, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK
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20
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van Miert C, Fernandes RM, Eccleson H, Bedson E, Lane S, Peak M, Thorburn K, Compton V, Woolfall K, Lacy D, Williamson P, McNamara PS. Non-invasive ventilation for the management of children with bronchiolitis (NOVEMBR): a feasibility study and core outcome set development protocol. Trials 2018; 19:627. [PMID: 30428935 PMCID: PMC6236891 DOI: 10.1186/s13063-018-2969-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Bronchiolitis is an acute lower respiratory infection which predominantly affects young children. Treatment for bronchiolitis is limited to supportive therapy. Nasal oxygen therapy is part of routine care, and delivery now incorporates varying levels of non-invasive continuous positive airway pressure and/or high-flow nasal cannula oxygen therapy. Despite wide clinical use, there remains a lack of evidence on the comparative effectiveness and safety of these interventions. Furthermore, research in this field is hampered by the use of multiple outcome measures in current clinical trials. METHODS/DESIGN This mixed methods study includes a systematic review of outcome measures, telephone interviews with parents, focus group workshops and a Delphi survey with healthcare professionals and parents. These methods will be used to identify and prioritise outcomes for inclusion in a core outcome set and to explore issues pertinent to the design of a future randomised controlled trial comparing different modes of oxygen therapy for bronchiolitis. UK hospitals will also be contacted and asked to complete a survey to provide an overview of current practice to enable assessment of capability and capacity to run a future clinical trial. DISCUSSION This study will facilitate the design of a future clinical trial of non-invasive ventilation in children with bronchiolitis which is acceptable to important stakeholders. Furthermore, core outcome set development will improve standardisation, measurement and reporting of clinically important outcomes in bronchiolitis. TRIAL REGISTRATION ISRCTN Registry, ISRCTN75766048. Registered on 18 December 2017. This study was retrospectively registered in the ISRCTN Registry and on the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database (15 September 2017).
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Affiliation(s)
- Clare van Miert
- School of Nursing and Allied Health, Liverpool John Moores University, Room 3.12 Henry Cotton Building, 15-21 Webster Street, Liverpool, L3 2ET UK
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Ricardo M. Fernandes
- Clinical Pharmacology Lab/Unit, Faculty of Medicine and Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
- Department of Pediatrics, Hospital Santa Maria, Lisbon, Portugal
| | - Helen Eccleson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool, Institute of Child Health, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP UK
| | - Emma Bedson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool, Institute of Child Health, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP UK
| | - Steven Lane
- Department of Biostatistics, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Kent Thorburn
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Vanessa Compton
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Kerry Woolfall
- MRC North West Hub for Trials Methodology Research Institute of Psychology, Health and Society, Block B, Room B112, 1st Floor Waterhouse Building, Liverpool, L69 3GL UK
| | - David Lacy
- Department of Paediatrics, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Road, Upton, Wirral, CH49 5PE UK
| | - Paula Williamson
- Department of Biostatistics, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Paul S. McNamara
- Institute of Child Health, University of Liverpool, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
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Fish R, Sanders C, Ryan N, der Veer SV, Renehan AG, Williamson PR. Systematic review of outcome measures following chemoradiotherapy for the treatment of anal cancer (CORMAC). Colorectal Dis 2018; 20:371-382. [PMID: 29566456 PMCID: PMC5969105 DOI: 10.1111/codi.14103] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/26/2018] [Indexed: 12/18/2022]
Abstract
AIM Six Phase III randomized trials have determined the effectiveness of chemoradiotherapy as primary treatment for anal squamous cell carcinoma (ASCC), but outcomes reported in these trials varied widely, hindering evidence synthesis. To improve reporting in all future trials, we aim to develop a core outcomes set (COS). As the first stage of COS development, we undertook a systematic review to summarize the outcomes reported in studies evaluating chemoradiotherapy for ASCC. METHOD Systematic literature searches identified studies evaluating radiotherapy or chemoradiotherapy for ASCC. Outcomes and accompanying definitions were extracted verbatim and categorized into domains. RESULTS From 5170 abstracts, we identified 95 eligible studies, reporting 1192 outcomes and 533 unique terms. We collapsed these terms into 86 standardized outcomes and five domains: survival; disease activity; life impact [including quality of life (QoL)]; delivery of care; and toxicity. The most commonly reported domains were survival and disease activity, reported in 74 (86%) and 54 (62%) studies, respectively. No outcome was reported in every publication. Over half (43/86) of the standardized outcome terms were reported in fewer than five studies, and 21 (25%) were reported in a single study only. There was wide variation in definitions of disease-free survival, colostomy-free survival and progression-free survival (PFS). Anal continence was reported in only 35 (41%) studies. CONCLUSION Outcomes reported in studies evaluating chemoradiotherapy for ASCC were heterogenous and definitions varied widely. Outcomes likely to be important to patients, such as ano-rectal function, toxicity and QoL, have been neglected. A COS for future trials will address these issues.
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Affiliation(s)
- R. Fish
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Peritoneal and Colorectal Oncology CentreChristie NHS Foundation TrustManchesterUK
| | - C. Sanders
- Centre for Primary CareUniversity of ManchesterManchesterUK
| | - N. Ryan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and Health Fifth Floor ‐ ResearchSt Mary's HospitalUniversity of ManchesterManchesterUK
| | - S. Van der Veer
- Centre for Health InformaticsInformatics, Imaging and Data ScienceSchool of Health SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Farr Institute of Health Informatics ResearchHealth eResearch CentreUniversity of ManchesterManchesterUK
| | - A. G. Renehan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Peritoneal and Colorectal Oncology CentreChristie NHS Foundation TrustManchesterUK
| | - P. R. Williamson
- MRC North West Hub for Trials Methodology ResearchDepartment of BiostatisticsUniversity of LiverpoolLiverpoolUK
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